Traditional Practices, Traditional Spirituality, and AlcoholCessation Among American Indians*

ROSALIE A. TORRES STONE, PH.D.,t LES B. WHITBECK, PH.D., XIAOJIN CHEN, PH.D.,t KURT JOHNSON, PH.D., ANDDEBBIE M. OLSON, M.A.

Department of Sociology, University of Nebraska-Lincoln, 703 Oldfather Hall, Lincoln, Nebraska 68588-0324

ABSTRACT. Objective: The detrimental effects of alcohol misuse anddependence are well documented as an important public-health issueamong American Indian adults. This preponderance of problem-centeredresearch, however, has eclipsed some important resilience factors asso-ciated with life course patterns of American Indian alcohol use. In thisstudy, we investigate the influence of enculturation, and each of the threecomponent dimensions (traditional practices, traditional spirituality, andcultural identity) to provide a stringent evaluation of the specific mecha-nisms through which traditional culture affects alcohol cessation amongAmerican Indians. Method: These data were collected as part of a 3-year lagged sequential study currently underway on four American In-dian reservations in the upper Midwest and five Canadian First Nationreserves. The sample consisted of 980 Native American adults, with 71%women and 29% men who are parents or guardians of youth ages 10-12 years old. Logistic regression was used to assess the unique contri-

bution of the indicators of alcohol cessation. Excluding adults who hadno lifetime alcohol use, the total sample size for present analysis is 732adult respondents. Results: The findings show that older adults, women,and married adults were more likely to have quit using alcohol. Whenwe examined the individual components of enculturation, two of thethree components (participation in traditional activities and traditionalspirituality) had significantly positive effects on alcohol cessation. Con-clusions: Although our findings provide empirical evidence that tradi-tional practices and traditional spirituality play an important role inalcohol cessation, the data are cross-sectional and therefore do not in-dicate direction of effects. Longitudinal studies are warranted, in lightof the work that concludes that cultural/spiritual issues may be moreimportant in maintaining sobriety once it is established rather than ini-tiating it. (J. Stud. Alcohol 67: 236-244, 2006)

T HE DETRIMENTAL EFFECTS OF ALCOHOL mis-use and dependence are well documented as an impor-tant public health issue among American Indians (Centersfor Disease Control, 2001; May, 1994; May and Gossage,2001). Rates of preventable deaths among American Indianadults are 133% higher than their European American coun-terparts (Snipp, 1997), and most of these preventable deathsare alcohol-related (May, 1994). Among Native people ages25-44 years old, death rates from liver disease are six timesgreater than for European Americans (Snipp, 1997). In theurgency to understand this important public-health issue,there have been hundreds of studies of correlates of alco-hol dependence and misuse among American Indians. How-ever, this understandable preponderance of problem-centeredresearch has eclipsed some important resilience factors as-sociated with life course patterns of American Indian alco-hol use.

Received: June 9, 2005. Revision: September 12, 2005.*This research was supported by National Institute on Drug Abuse grant

DA13580 and by National Institute of Mental Health grant MH67281 to LesB. Whitbeck, principal investigator.

tCorrespondence may be sent to Rosalie A. Torres Stone at the aboveaddress, or via email at: rstone2@unl.edu. Xiaojin Chen is with the Depart-ment of Sociology, Tulane University, New Orleans, LA.

Although there have been few studies of rates or corre-lates of natural remission from alcohol in the general popu-lation (Sobell et al., 2000), there is a small but importantliterature emerging that pertains to American Indians. Thesepatterns of natural remission may represent a critical cul-tural resilience factor that has enormous potential for pre-vention and treatment programs. We believe that this keyconstruct has to do with cultural influences, in particular,traditional spirituality. In this article, we investigate corre-lates of maintenance of sobriety among American Indianadults who live on or near rural and remote reservations inthe northern Midwest United States and Ontario, Canada.We examined the relative effects of alcohol and drug treat-ment along with other factors in the respondent's lives,such as traditional practices and spirituality, that may influ-ence cessation and maintenance of sobriety.

There is consistent evidence that alcohol treatment pro-grams are successful in ceasing addictive behavior (Anglinand Hser, 1991; Carroll, 1993; Fiorentine and Hillhouse,2001). There is, however, increasing evidence that indi-viduals with alcohol addictive behaviors remit without treat-ment or self-help groups (Sobell et al., 1993, 1996; Toneattoet al., 1999; Tucker, 1999). In two Canadian studies, morethan 70% of respondents with alcohol-related problems hadrecovered without formal treatment (Sobell et al., 1996). In

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another study, 4.2% of the respondents had used formalintervention, such as Alcoholics Anonymous, to quit drink-ing (Bezdek et al., 2004). The research on natural recoveryshows that social capital (characterized by few social prob-lems and a high degree of social support; Bischolf et al.,2003), cognitive appraisals (characterized as weighing theperceived costs and benefits of continuing to drink; Sobellet al., 1993, 1996), and severity of alcohol-related prob-lems (Bischolf et al., 2003) are important enabling factorsof the process of natural recovery. Some studies, however,have found that neither alcohol nor drug problem severitysignificantly predicted abstinence in either treatment ornontreatment groups (Weisner et al., 2003). The researchon natural recovery implies that recovering from addictivebehaviors is contextual and varies by individuals.

Cross-cultural comparisons on alcohol cessation showthat American Indians report "natural" remission from al-cohol use earlier in life than do their European counter-parts (Bezdek et al., 2004; Kunitz and Levy, 1994, 2000;Spicer, 2001). Whereas spontaneous remission is likely af-ter age 60 among European Americans, the Navajos in theKunitz and Levy (1994) longitudinal studies quit drinkingin their 40s and 50s. Indeed, when asked about circum-stances that led to recovery, only 39% of the Navajo peoplein remission said that they quit because of treatment; theremaining gave reasons such as quitting on their own, fam-ily support, and religion (Kunitz and Levy, 2000). Spicerreported that the most significant finding in his recent re-port on natural recovery was the effects of religion andspirituality on maintaining sobriety (Spicer, 2001).

Correlates of alcohol misuse and dependence amongAmerican Indian adults

Numerous contextual factors contribute to the high ratesof alcohol misuse and dependency among American Indianadults. Recent studies indicate that heavy drinking is asso-ciated with being male, being young, having less than ahigh school diploma, and being unemployed (Beauvais,1998a; Herman-Stahl et al., 2003; May and Gossage, 2001).Westemeyer and Neider (1985), in a 10-year follow-up ofAmerican Indians treated for alcoholism, reported that thosewho remained abstinent were more likely to be marriedand employed than those who relapsed. Fillmore et al.(1997) found that marriage reduced alcohol consumptionamong both young women and men. For individuals wholeave reservations in search of employment, the potentialeconomic benefits of moving are often countered by thelack of support from their community and families(Milbrodt, 2002). Spicer and colleagues (2003) studied ratesof alcohol use and dependence in American Indian tribesfrom two regions: the Northern Plains and the Southwest.The sample consisted of individuals ages 15-54 years. Datarevealed regional variations in drinking patterns. In both

American Indian samples, being male and being in an olderage cohort (35-44 or 45-54) increased the risk of lifetimealcohol dependence. Poverty was not related to lifetime al-cohol dependence, but those individuals not working forpay were at increased risk among the Northern Plainssample. In the Southwest sample, being married decreasedthe risk of lifetime alcohol dependence. Self-reported healthis also associated with increased odds of alcohol use.Okosun et al. (2005) found that higher levels of heavy epi-sodic alcohol consumpiion (defined as the consumption offive or more [for men] and four or more alcohol beverages[for women] on one occasion) was associated with increasedlevels of self-rated poor health in black, white, and His-panic men and women. Being black or Hispanic, however,was associated with increased odds of poor self-relatedhealth relative to white people.

Enculturation as a protective factor

For many years, researchers concerned with AmericanIndian alcohol misuse have believed that "enculturation"-the degree an individual is embedded in his or her culturaltraditions as evidenced by traditional practices, traditionallanguage, traditional spirituality, and cultural identity(Whitbeck et al., 2004; Zimmerman et al., 1994)-is animportant factor in alcohol cessation and abstinence. Evi-dence continues to accumulate that enculturation may pro-tect against alcohol misuse or serve as an important curativefactor in alcohol-use treatment programs (Gray and Nye,2001; Herman-Stahl et al., 2003; Spicer et al., 2003).Herman-Stahl and colleagues (2003) reported that Ameri-can Indians with a low orientation toward traditional cul-ture were more than 4.4 times as likely to be heavy drinkers,compared with more culturally oriented adults. Biculturalindividuals were almost three times as likely to drink heavilyand 2.3 times as likely to have an alcohol-use disorder,compared with individuals with a high American Indian(or traditional) cultural orientation. Furthermore, there isevidence that enculturation is negatively associated withalcohol misuse among American Indian adults (Whitbecket al., 2004).

Although evidence is accumulating that traditional cul-ture plays an important role in alcohol cessation and main-tenance of sobriety, -we do not yet fully understand thespecific mechanisms through which it works. A small butimportant area of research has focused on the healing as-pects of traditional spirituality (Hazel and Mohatt, 2001;Lowery, 1998; Miller, 1998; Westermeyer and Neider,1985). In an important recent study, Hazel and Mohatt(2001) showed that little research on alcohol cessation hasbeen situated in an American Indian cultural spiritual con-text. Rather most research has constructed spirituality inthe Judeo-Christian sense such as that through the Alcohol-ics Anonymous 12-step program.

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A "crisis of the spirit"

For many among the American Indian community, ad-diction is regarded as "a crisis of the spirit," a result ofcolonization, discrimination, internalized racism, and preju-dice (Duran and Duran, 1995; Lowery, 1998). Quintero(2001) argued that colonialism is most dangerous in its ef-fect on the Americans Indians' self-concept when they in-ternalize the negative attributions and prejudices of themajority culture. Duran and Duran (1995) reconceptualizealcohol use from the point of view of traditional culture asa spirit that must be encountered and fought in traditionalways to restore natural harmony in human lives (Raymond,1983). This approach takes the problem out of the colonialcontexts of western psychology and places it within therealm of traditional belief systems and traditional healingprocesses. Hazel and Mohatt (2001) define sobriety as "aprocess of opening to what the Yup'ik refer to as Ellam-iinga-the eye of awareness or eye of God." When an in-dividual becomes addicted to alcohol or another substance,their spiritual relationship and connectedness to the worldaround them is closed. Therefore, sobriety is seen as a wayin which to reconnect with one's self and one's surround-ings, rekindling their spiritual side in the process. Theirresearch suggests that those individuals who experienced acessation in alcohol use also experienced an awakening intheir spiritual life.

That spirituality plays a role in alcohol cessation is not anew concept. It is the core of the Alcoholics Anonymous12-step program. A study of participants in AlcoholicsAnonymous found that the extent of practice of Step 11(prayer and meditation, spending time with nature) was posi-tively correlated with both purpose of life and length ofsobriety (Carroll, 1993). In other studies of recovering al-coholics, Kaskutas et al. (2003) and Poage et al. (2004)found that sobriety was positively associated with spiritual-ity. Kaskutas et al. (2003) examined the role of religiosityover a 3-year span on a sample of 587 men and womeninvolved with Alcoholics Anonymous. Controlling for otherinfluences, they found that individuals who reported a spiri-tual awakening at Year 3 had the highest odds of sobriety.Hazel and Mohatt (2001) found that the majority of partici-pants (74%) in their study of Alaska Natives indicated thattheir reason for alcohol cessation was a "single event." Only11%, however, of this group mentioned that the event wasof a spiritual nature rather than an aversive nature (46%).Their findings suggested that spirituality might be moreimportant in maintaining the recovery process rather thanthe most important reason for cessation. Among recoveringalcoholics, 44% of respondents found support in spiritual-ity, with 43% mentioning Native culturally based spiritual-ity (Hazel and Mohatt, 2001).

In the current study, we investigate the influence ofenculturation and each of the three component dimensions

(traditional practices, traditional spirituality, and culturalidentity) to provide a stringent evaluation of the specificmechanisms through which traditional culture affects alco-hol cessation among American Indian adults. Our analysesinclude numerous other potential correlates of alcohol ces-sation, including marital status, number of children, finan-cial strain, a biological parent who has been in treatmentfor alcohol or drug misuse, self-reported health, self-reportedproblems as a result of substance misuse, and participatingin an inpatient treatment program for alcohol or drug use.

Method

Sample

These data were collected as part of a 3-year laggedsequential study currently underway on four American In-dian reservations in the upper Midwest of the United Statesand on five Canadian First Nation reserves. Four of theCanadian Reserves are classified as remote, in that they areconsiderably distant from even small towns and are ac-cessed by nonpaved roads, by boat, over ice in winter, orby airplane. Data are from Wave I of the study collectedon two U.S. reservations and one Canadian Reserve fromFebruary 2002 through October 2002 and from Wave 1 ofthe second group of two U.S. reservations and the fourremote Canadian Reserves collected from February 2002through October 2003. The reserves and reservations sharea common cultural tradition and language, with minor re-gional variations in dialects. The sample represents one ofthe most populous Native cultures in the United States andCanada. The purpose of this project is to identify culturallyspecific resilience and risk factors that affect children's well-being and then to use the information to guide the develop-ment of culturally based interventions.

The project was designed in partnership with the partici-pating reservations. Before application funding, the researchteam was invited to work on these reservations, and tribalresolutions were obtained. As part of our agreement to worktogether the researchers promised that participating reser-vations would be kept confidential in published reports. Oneach participating reservation, an advisory board represent-ing all reservation districts was appointed by the tribal coun-cil. The advisory boards were responsible for handlingdifficult personnel problems, advising on questionnaire de-velopment, reading reports for respectful writing, and en-suring that published reports protected the identity of theculture. All participating staff on the reservations were ap-proved by the advisory board and were either tribal mem-bers or in a few cases nonmembers who are spouses oftribal members. To ensure quality of data collection, all theinterviewers underwent special training for conducting penciland paper and computer-assisted personal interviewing for

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the diagnostic measures. The training included practice andfeedback sessions.

Families were recruited with a personal visit by an in-terviewer in which the project was explained to them; theywere presented with a gift of wild rice and invited to par-ticipate. To participate in the project, the study respondenthad to be either a parent or guardian of youth ages, 10-12.If they agreed to be interviewed, each family member re-ceived U.S. $40 for their time when the interviews werecompleted. The recruitment procedure resulted in an over-all response rate of 79.4%. In this type of research, a re-sponse rate of 70% is usually viewed as acceptable.

Sample characteristics

The sample for this analysis consisted of 980 AmericanIndian adults, with 71% women and 29% men. The age ofthe women ranged from 17 to 77 years old, with an aver-age (SD) of 39 (9.58) years. Similarly, the age of maleadults ranged from 21 to 68 years old, with a mean of 42(9.78). In terms of family structure, approximately one third(36%) of the families contained two biological parents, and23% were single-mother-headed households. Other fami-lies were made up of various configurations, includingmother and stepfather (10%), mother living with other rela-tives (e.g., grandmothers, aunts, uncles; 7%), single bio-logical fathers (4%), living with grandparents (7%), or othermultigeneration households. Predictably, the distribution ofincome in this sample varies greatly according to familystructure. Single-parent households were twice as likely astwo-parent households (includes stepfathers and live-ins)to have incomes of $15,000 or less (46.0% vs 23.5%). Morethan one fourth (27.9%) of single-parent households weregetting by on $10,000 or less per year. Median income forsingle-parent families was under $20,000, compared withabout $25,000 for two-parent families. Financial assistancewas also common. About one half of single-parent (53.5%)households and one third of two-parent households (34.7%)received food stamps. Approximately one half (44.0%) ofsingle-parent households and 28.9% of two-parent house-holds received family assistance (Temporary Assistance forNeedy Families) or the Canadian equivalent in the past year.

The majority of.the respondents live on reservations thatare embedded in the context of the majority culture andrequire nearly daily interaction with members of the major-ity culture. Four of the five reservations have casinos in theUnited States, and they are proximate to the majority cul-ture. Much of their trade and commerce takes place in lo-cal majority culture population centers. The primarylanguage used in the schools (both on and off reservation)is English. Given the educational system and the biculturaleconomic and social context of these reservations, it is notsurprising that all of our respondents were English speak-ing. Also, consider that these are reservations in which many

from the grandparent generation were removed from thereservation in a forced acculturation program-a fact thathad an important impact on the transmission of the nativelanguage. In this sample, although two thirds of the re-spondents indicate that they can speak some native lan-guage, only 15.1% indicate that they are fluent nativespeakers.

Measures

Alcohol cessation was measured as a dichotomous vari-able, indicating they no longer drank alcohol after a priorperiod of alcohol use or abuse. Respondents who had neverdrank in their lifetime, who had not had at least 12 drinksin their lifetime, or who had not had 12 drinks in any yearin their lifetime were defined as nonalcohol users. Thesenonalcohol users (n = 133) were excluded from currentanalysis. Among those who had alcohol before, 37% re-ported that they stopped using alcohol.

Parental alcohol treatment was a dichotomous measureof whether either biological mothers, biological fathers, orboth had ever received treatment for alcohol problems.Those respondents who answered "yes" for at least oneparent were coded as "1," and others were coded as "0."Sixteen percent of the respondents reported that their bio-logical mother and/or father had been under treatment foralcohol problems.

Financial strain was a scale consisting of four items thatasked respondents if they agree that their families haveenough money to afford the kind of home, clothing, food,and medical care that they need. Response categories werethe following: 1 = strongly agree, 2 = agree, 3 = disagree,and 4 = strongly disagree. Cronbach's a coefficient for thisscale was .83. The scale ranged from 2 to 16, with a meanof 2.50 (1.00).

Self-reported health was measured by a single item ask-ing about their general health, status. Response categorieswere the following: 1 = excellent, 2 = very good, 3 = good,4 = fair, and 5 = poor. The question was then inverselyrecoded, with the high number indicating better overallhealth status. The mean for self-reported health was 3.32(1.05).

Alcohol or drug treatment was measured by askingwhether and how many times respondents had gone throughalcohol or drug use treatment. The variable had a rangefrom 0 to 12 times in treatment. Thirty-four percent of therespondents reported that they had at least one treatment(with the average of two times for those who had beenthrough at least one treatment).

Alcohol or drug problems is a scale measured by sixindividual items. Respondents were asked if their drinkingor drug use frequently interfered with work at school, onthe job, or at home; whether their alcohol or drug use re-sulted in physical fights; whether alcohol or drug use caused

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trouble between a family member or a friend; whether re-spondents continued to drink or use drugs even after itcaused problems; whether they had been arrested becauseof alcohol or drug use; and whether they had been in aphysical fight with a spouse under the influence of alcoholor drugs. A count procedure was then used to compute acomposite scale. The scale ranged from 0 to 6, with a meanof 3.18 (1.99).

The historical loss scale measures the degree to whichrespondents report a sense of loss as a result of historicalloss. The scale consisted of 12 items, each listing a type ofloss, including loss of land, language, culture, traditionalspiritual ways, loss of family and family ties, loss of self-respect, loss of trust, loss of people through early death,and loss of respect by children for elders and for traditionalways (Whitbeck et al., 2004). Response categories werethe following: 1 several times a day, 2 = daily, 3 = weekly,4 = monthly, 5 yearly or at special times, and 6 = never.The scale has a high internal reliability, with Cronbach's xcoefficient of .94. The scale ranged from 0 to 9, with amean of 2.07 (1.09).

The measures of enculturation were developed in col-laboration with the participating tribes and were based onthe prior research that identifies three basic dimensions: (1)participation in traditional activities, (2) identification withAmerican Indian culture, and (3) traditional spirituality. Thetraditional activities scale was developed through focusgroups with elders and represents the mean of the stan-dardized values of three indicators: participation in tradi-tional pow-wow activities, knowledge and use of the triballanguage, and involvement in 19 types of traditional activi-ties. The a reliability coefficient (Cronbach's a) for thetraditional activities measure was .77. The cultural identifi-cation measure was adapted from Oetting and Beauvais's(1990-1991) American Indian cultural identification items.Respondents were asked four questions regarding (1) thedegree to which they participated in American Indian cul-ture, (2) how much their family lived by American Indianculture, (3) how much they lived by American Indian cul-ture, and (4) how much they lived by or followed Ameri-can Indian culture. Response categories ranged from 1 = alot to 4 = none. The scale scores were computed by takingthe mean response to the four items. As demonstrated inother work with this scale, it had high internal consistency(Cronbach's a = .87). Traditional spirituality was assessedby four global items; the respondents were asked (1) ifthey participated in traditional spiritual activities (0 = no, 1= yes), (2) how often they participated in such activities (1= everyday, 7 = never), (3) the importance of traditionalspiritual values for how they led their lives (1 = very im-portant, 4 = not at all important), and (4) their involvementin 16 traditional spiritual activities. Given the range in varia-tion in these component indicators, each of these four glo-bal items was standardized before calculating. The mean of

these four standardized values indicated levels of spiritual-ity. The a reliability was .81 for this four indicator scale.A composite measure of enculturation was computed usinga weighted factor score of these three component dimen-sions. Cronbach's a for this measure was .96.

Demographic factors

Age, gender, marital status, and number of children werecontrolled in the analysis. The average (SD) age of samplerespondents was 39.51 (9.62) years old. Gender was codedas 1 = female and 0 = male. Similarly, marital status wascoded as I = married or living together and 0 = others(mean = .64). The average number of children in the house-hold was 4.33.

Results

Logistic regression was used to assess the unique con-tribution of the indicators of alcohol cessation. Excludingadults who had no lifetime alcohol use, the total samplesize for present analysis is 732 adult respondents. These732 respondents were nested within 532 households, with55% having both a wife and husband interviewed. Twopersons from a single household are likely to share someresilience, risk exposure, and environmental influences incommon; therefore, they may not provide independent ob-servations. The nonindependence of these "nested" obser-vations in the sample needs to be addressed in the modelestimation. In the context of logistic regression models, theestimations of model parameters will be unbiased, but thereis a potential bias in the estimates of the standard errors(Lee et al., 1989). To produce correct estimates of standarderrors and hence accurate hypothesis testing, classical sta-tistical techniques (i.e., maximum-likelihood estimator inthis case) assume that samples are independent. This as-sumption, however, is not met in nested data. To addressthis issue, we used Mplus 3.0 to compute standard errorsand chi-square tests of model fit, taking into accountnonindependence of observation (Muth6n and Muth6n,2004). Corrected standard errors were obtained by using asandwich estimator (Muth6n and Muth6n, 2004). This esti-mator adjusts the standard errors for the nested nature ofthe sample and corrected estimates of the significance ofthe logistic regression model parameters.

Bivariate correlations

Bivariate correlations for all of the variables in the re-gression models are presented in Table 1. Alcohol cessa-tion was significantly and positively associated with age (r= .26), number of children (r = .15), previous alcohol prob-lems (r = .08), participation in traditional activities (r =.22), culture identity (r = .18), and involvement in spiritual

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TABLE 1. Correlation matrix

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14

L. Alcohol cessation 1.002. Age .26t 1.003. Gender (female = 1) .01 -.151 1.004. Marital status .05 -.04 -.21t 1.005. No. of children .151 .30t -.07 .07* 1.006. Biological parental

alcohol treatment -.10 -.181 .05 -.03 -.01 1.007. Financial strain .04 -.03 .10l -.151 .07 .1 it 1.008. Self-reported health -.10l -.271 -.03 .07 -.131 .04 -.25t 1.009. Times in alcohol/

drug treatment .06 .02 -.201 -.05 .06 .09* .09* -.04 1.0010. Alcohol/drug problems .08* .02 ,.16t -.03 .05 .10l .16 -..14t .391 1.00

11. Historical loss .06 .00 .01 -.01 .07 .10t .10t -.05 .09* .10t 1.00

12. Traditional activity .221 .03 -.15t .02 li1 .07 -.05 -.01 .08* .08* .32t 1.00

13. Cultural identity .181 .111 .02 -.06 .121 .04 -.05 -.06 .03 -.03 .32t .581 1.00

14. Spirituality .231 .07* -.02 -.03 .it .07* -.03 -.05 .lt .08* .391 .681 .62t 1.00

Mean 0.37 39.51 0.71 0.64 4.43 0.27 2.50 3.32 0.69 3.18 2.07 0.00 0.03 0.04

SD 0.48 9.62 0A6 0.48 2.22 0.44 1.00 1.05 1.37 1.99 1.09 1.00 0.95 0.93

Note: N = 757.*p < .05; tp < .01.

activities (r = .23). Specifically, American Indian adultswho were older, lived with a greater number of children,had previous alcohol-related problems, and had strongerconnections with their native culture were more likely tostop using alcohol. In contrast, self-reported overall healthwas negatively related with alcohol cessation (r = -.10).

Multivariate analyses

Table 2 presents results of the step-wise logistic regres-sion analysis. In Model 1, demographic factors (such asage, marital status, and number of children in the house-

hold) were significantly associated with alcohol cessationamong the American Indian adults. Older adults were morelikely to have stopped using alcohol (Exp(b) = 1.05); thosewho were married were almost one and one-half times(Exp(b) = 1.42) more likely to have stopped using alcoholthan those who were not married, divorced, or widowed. InModel 2, having a biological parent who had been in inpa-tient treatment for substance misuse was added to the model,and the coefficient was nonsignificant. Self-reported healthstatus was added in Model 3 and was nonsignificant. InModel 4, a history of problems with alcohol was added,and it was positively associated with alcohol cessation

TADLE 2. Logistic regression model predicting alcohol cessation among American Indian adults (N= 732)

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6a Model 6b

b Exp(b) b Exp(b) b Exp(b) b Exp(b) b Exp(b) b Exp(b) b Exp(b)"Vrn4lahle

AgeGender (female = 1)Marital status

(married= 1)No. of childrenFinancial strainBiological parent

treatmentSelf-reported healthAlcohol problemsAlcohol treatmentEnculturationTraditional activitiesCultural identitySpiritualityConstantModel X2

Step model X2

Cox & Snell pseudo R2

0.05 1.05t 0.05 1.05t 0.05 1.05t 0.05 1.05t 0.05 1.051 0.04 1.04t 0.05 1.05t

0.35 1.42 0.35 1.42 0.33 1.39 0.42 1.52* 0.47 1.59* 0.60 1.84t 0.63 1.90t

0.35 1.42* 0.35 1.41* 0.35 1.42* 0.37 1A4* 0.38 1.47* 0.42 1.53* 0.44 1.55*0.08 1.08* 0.08 1.09* 0.08 1.08* 0.08 1.08* 0.08 1.08* 0.06 1.07 0.05 1.05

-0.07 0.94 -0.06 0.94 . -0.10 0.91 -0.13 0.88 -0.13 0.87 -0.11 0.93 -0.10 0.91

-0.15 0.86 -0.14 0.87 -0.18 0.84 -0.19 0.83 -0.29 0.75 -0.29 0.75-0.14 0.86 -0.12 0.89 -0.12 0.89 -0.14 0.87 -0.12 0.89

0.10 1.11* 0.08 1.09 0.09 1.09 0.08 1.080.08 1.09 0.05 1.04 0.07 1.07

0.54 1.71* - -0.39 1.481

-0.03 0.970.29 1.34*

-3.38 0.03 -3.30 0.04 -2.67 0.07 -3.17 0.04 -2.74 0.07 -1.98 0.14 -2.00 0.13

56.03t 56.69t 59.67t 65.47t 67.29t 113.511 112.70t- 0.66 2.98 5.8* 1.82 46.221 45.421

0.07 0.07 0.08 0.09 0.09 0.13 0.14

Note: Bold indicates statistical significance.*p< .05; tp< .01.

Variable

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(Exp(b) = 1.11). Thus, the more disruptive the drinking,the greater the likelihood was of remission. Gender becamestatistically significant in Model 4 and was positively re-lated to alcohol cessation (Exp(b) = 1.52), indicating thatwomen were more likely to have stopped drinking thanmen when the preceding variables were in the equation. InModel 5, having ever been in an inpatient treatment pro-gram for alcohol or drug use was added to the equationand was nonsignificant. Enculturation was added in Mod-els 6a and 6b. In Model 6a, we added the compositeenculturation measure. In this model, enculturation has asignificant effect (Exp(b) = 1.71). We then examinedwhether the effects of enculturation would appear to be theresult of certain factors by estimating the independent in-fluences of the three dimensions in Model 6b. Of the threedimensions of enculturation, traditional activities (Exp(b) =1.48) and traditional spirituality (Exp(b) = 1.34) were sta-tistically significant, and cultural identity was nonsignificant.

Discussion

In this study, we investigated correlates of alcohol ces-sation among American Indian adults. We also examinedthe relative effect of alcohol and drug treatment with otherfactors in the respondent's lives-such as traditional prac-tices, spirituality, and cultural identification-that might in-fluence cessation and maintenance of sobriety.

In many respects, our findings were congruent with pre-vious research. Older adults, females, and married adultswere more likely to have quit using alcohol. That olderindividuals were more likely to stop drinking supports evi-dence that some "mature out" of alcohol misuse (Sobell etal., 2000). The research, however, shows that this tends tobe more common for women than for men and sometimesoccurs when family responsibilities begin (Lemart, 1982;May and Smith, 1988). Our findings that being a womanand being married were associated with alcohol cessationalso support previous research (Spicer et al., 2003). Wewere surprised, however, and puzzled by the number ofvariables that did not significantly influence alcohol cessa-tion, particularly self-reported inpatient alcohol or drug usetreatment and self-reported health. Although poor self-re-ported health is associated with heavy drinking (Okosun etal., 2005), our results show that it is not significant in pre-dicting alcohol cessation.

We considered the impact of enculturation and the com-ponent dimensions in the final model. Overall, enculturationhas a significant positive effect, and it remains the onlysignificant predictor of alcohol cessation other than the pre-viously noted contributions of some control variables. Whenwe examined the individual components of enculturation,two of the three-participation in traditional activities andtraditional spirituality-had significantly positive effects onalcohol cessation. These findings are consistent with re-

search that suggest enculturation serves as a resiliency fac-tor that may protect against alcohol misuse or serve as animportant curative factor in alcohol treatment programs(Gray and Nye, 2001; Herman-Stahl et al., 1993; Spicer etal., 2003). Moreover, they provide some intriguing evidenceconcerning the specific mechanisms through whichenculturation works.

Cultural identity was not significantly associated withalcohol cessation in the multivariate analysis. This findingis congruent with negative findings in other research thathas attempted to link cultural identity to alcohol cessation.Beauvais (1998b), in a recent literature review regardingcultural identification, concludes that research has yet todemonstrate direct effects for cultural identification on sub-stance misuse among adolescents. As Beauvais (1998b)notes, "Despite the paucity of findings, most investigatorsare unwilling to concede that a higher level of identifica-tion with culture is not, in some way, 'protective' againstsubstance use" (p. 1331). It may be the case that practicesand spirituality are better measures of enculturation thancultural identity.

The finding that alcohol inpatient treatment was nonsig-nificant does not necessarily mean that treatment is inef-fective. It may well be that the teaching of and commitmentto traditional practices and traditional spirituality were theresult of culturally based alcohol- or drug-use treatmentprograms. Although we checked for a statistically signifi-cant interaction between inpatient treatment and theenculturation variables, it could be that traditional practicesand spirituality socialized in these programs were givencredit for alcohol cessation rather than the treatment pro-grams themselves. We have no way of teasing out thesenuances with our data.

Limitations

Although these findings provide promising support thattraditional practices and spirituality are important factors inalcohol cessation and sobriety among American Indianadults, they should be regarded with appropriate caution.First, the results are from a single culture and may not begeneralizable across the diversity of American Indian,Alaska Natives, and Canadian First Nations people. Sec-ond, even though our data are from several sites, they re-flect the attitudes and behaviors of people who live on ornear rural reservations. They may not represent urbanAmerican Indians even from the same cultural background.Third, the data are from parents or guardians of childrenages 10-12 years old. They represent people at a particularstage of life and those who are rearing children rather thana population sample of American Indian adults. Fourth, thedata are cross-sectional, which always raises questions re-garding the direction of hypothesis causal effects. Longitu-dinal studies are warranted in light of the work, which

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concludes that cultural/spiritual issues may be more impor-tant in maintaining sobriety once it is established ratherthan initiating it (Hazel and Mohatt, 2001; Sobell et al.,1993). Hazel and Mohatt found that, of those who attrib-uted alcohol cessation to a single event, only 11% men-tioned that the event was of a spiritual nature, rather thanan aversive nature (46%). In another study, the majority(57%) of the recoveries were characterized as involvingcognitive appraisals of the pros and cons of drinking. How-ever, 20% of resolved subjects endorsed religious influenceas helpful in maintaining their recovery 1-12 monthspostresolution (Sobell et al., 1993). This has important im-plications for treatment, in that treatment programs mayhave to focus initially on aversive events (e.g., loss of arelationship), cognitive appraisals (pros and cons of drink-ing), or both early on in treatment and then gradually inte-grate cultural/spiritual elements to sustain the sobriety.

Another limitation is that measurement procedures relyexclusively on self-report. Because some proportions of al-cohol abusers' self-reports are inaccurate, collateral reportsor official records are often used to validate self-reporteddata (Maisto and Connors, 1992). Some researchers havefound that the use of collaterals leads to more accurateself-report (Cunningham et al., 2004). Cunningham et al.(2004) found that respondents who provided collaterals re-ported consuming more alcohol (or experienced more con-sequences), compared with those asked for a collateral butwho did not provide one. Some researchers, however, findthat collateral/subject agreement depends on how confidentthe collateral is of the information, and the best agreementoccurred for reports from spouses (Sobell et al., 1997).Given the high prevalence of lifetime alcohol use (98.1%)and diagnostic estimate of lifetime alcohol abuse (68.1%)reported in our sample, underreporting of alcohol use maynot be much of a limitation in this study.

Irnplicationsforprevention/intervention: Incorporatingspirituality

Our findings suggest that pattems of natural remissionmay represent a critical cultural resilience factor that hasenormous potential for prevention and treatment programs.Duran and Duran (1995), Hazel and Mohatt (2001), Lowery(1998), and many others have indicated that alcohol cessa-tion among American Indian people may be more possiblewhen alcohol misuse is placed in cultural context. Thismeans that the definition of the problem should be con-structed in traditional terms and the intervention should re-spond to that definition and worldview. Antonovsky (1979)considers "culture" as a way a group answers the questionsthey face on a daily basis, gives a sense of place in theworld, and provides a worldview appropriate to that struc-ture. This creates a "sense of coherence" or a "long-lastingway of seeing the world and one's life in it" (Lowery,

1998, p. 129). The sense of coherence of a people is en-hanced because individuals can receive help and supportfrom the spiritual world. As Lowery (1998) points out:

We must acknowledge that alcoholism is a crisis of thespirit. We must acknowledge that this crisis requires ahealing of the spirit, of the mind, and of the body withina larger framework of existence, the extended familynetwork nested within the community clan, tribe, andnation. (p. 130)

Thus, the "emic perspective [italics added] calls for a cul-tural-specific framework in which behavior within the cul-ture can be examined and American Indian women can beunderstood on their own terms" (Lowery, 1998, p. 127).

Acknowledging and using this worldview may well bethe key to alcohol cessation for many American Indians.There are numerous alcohol misuse treatment and preven-'tion programs that incorporate traditional cultural practicesand traditional spirituality, but there is little empirical evi-dence regarding their efficacy. We believe these findingsprovide empirical support for the incorporation of tradi-tional practices and traditional spirituality in treatment andprevention programs for American Indians.

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TITLE: Traditional Practices, Traditional Spirituality, and AlcoholCessation

SOURCE: Journal of Studies on Alcohol 67 no2 Mr 2006PAGE(S): 236-44

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