ATTC’s Pearls of Wisdom: Learning from Indigenous Ways of Knowing

By Meg Schneider, communications coordinator, National American Indian/Alaska Native ATTC

"I have seen that in any great undertaking it is not enough for a man to depend simply upon himself."
- Lone Man (Isna-la-wica), Teton Sioux

Western science has relatively recently come to understand the importance of social wellness in promoting better physical, mental, emotional, and spiritual health. Community is a foundational component of virtually every Indigenous society and has been since time immemorial. Thousands of years of experience have taught Indigenous peoples the individual and collective benefits of cultivating strong community ties.

When the COVID-19 pandemic forced nearly universal shutdowns in March 2020, our Native friends and colleagues told us that one of the most devastating aspects of the health crisis was the sudden absence of in-person get-togethers. Ceremonies, celebrations, even community meals were no longer available to nurture and strengthen these communities, and the social hurt was almost as damaging as the virus itself.

Drumming at a Native powwow

Powwows, fairs, and other in-person gatherings are returning to Indigenous communities after more than two years of COVID-19-induced isolation. Finding ways to maintain connections during the pandemic was critically important to supporting physical, mental, emotional, and spiritual health. (Photo: Shutterstock.)

Indigenous communities suffered disproportionately from COVID-19: Compared with white non-Hispanic persons, they were 1.6 times more likely to contract the disease, 3 times more likely to be hospitalized, and 2.1 times more likely to die, according to the Centers for Disease Control and Prevention. When vaccines became available, American Indians and Alaska Natives had one of the highest inoculation rates in the U.S., yet COVID-related morbidity and mortality among this population continued to be higher than for other groups.

Over the past 25 years, the National American Indian and Alaska Native ATTC (first known as Prairielands ATTC, serving four Midwestern states when it launched in 1998) has adopted as a guiding principle the truth that Indigenous communities are the experts in what they need and what works for them. 

Rather than dictate how they addressed the enforced isolation imposed by the pandemic, we held a series of listening sessions to find out what these communities needed and brainstormed ways we could help address those needs.

Feedback from these listening sessions led to the development of several culturally informed programs: 

  • Virtual Native Talking Circle: Staying Connected in Challenging Times series (with 47 sessions and counting, most recently March 13, 2023). 
  • Winter Living Series and Spring Living Series, focusing on cultural ways of connecting during these seasons. 
  • Care and Share Through Technology, which first ran weekly and eventually monthly for Tribal Opioid Response grantees and has since been expanded to all addiction, prevention, treatment, and recovery professionals serving Native populations; and 
  • Keeping the Fire, a three-part series on personal and collective barriers to healthier living and ways to lower those barriers.

Face-to-face gatherings are still highly preferred among our Indigenous colleagues and communities. Adapting to technology-based alternatives during the restrictions of the pandemic helped ease some of the stress and grief induced by both the physical challenges of COVID-19 and the isolation that prohibited traditional ways of connecting with others. Like Lone Man, the staff at the National AI/AN ATTC have learned how critical interpersonal relationships and community connections are to the success of any undertaking, great or small.

We also have learned the importance of honoring visitors, colleagues, and those we serve. 

In many Indigenous cultures, such honoring is demonstrated via the presentation of gifts that are meaningful in the culture from which they come. The National AI/AN ATTC staff believe the most meaningful gifts we can offer are tools and resources to help Indigenous communities thrive. Thus we devote many of our own resources to developing things like the TOR Resource Guide and our monthly Essential Substance Abuse Skills (ESAS) trainings. As always, these offerings originate from those we serve, who generously share their insights and expertise on what they need to continue and improve the important work they do.

We are honored and grateful to be able to learn so much from the people we aim to serve. And we are eager to see what lessons the next 30 years hold. 

NIATx in New Places: Building Cultural Intelligence and Health Equity

By: Alfredo Cerrato, Senior Cultural and Workforce Development Officer,

NIATx has been a vehicle for innovation since introducing process improvement tools and techniques to substance use disorder treatment organizations in 2003. The five NIATx principles combined with the essential NIATx tools have transformed approaches to treatment access and retention for countless organizations across the nation.

That spirit of innovation endures as NIATx breaks ground in new service areas and settings. One exciting new area where we’re field-testing the NIATx approach is in organizational efforts to build cultural intelligence and health equity.

The growing diversity of the U.S. population requires a culturally-informed behavioral health workforce that can provide culturally and linguistically appropriate services.

NIATx tools and techniques can help a team identify and remove access barriers for underserved communities, such as those with limited English proficiency or low health literacy. The NIATx tools can be adapted to target equity and inclusion aims. For example:

·       The walk-through strategy can identify areas where cultural responsiveness is lacking, such as inadequate language assistance services or culturally appropriate materials. By involving clients (NIATx Principle #1) and staff from diverse backgrounds in the walk-through process, agencies can pinpoint barriers to care and spark ideas for improvement that prioritize cultural responsiveness.

·       The nominal group technique can generate and prioritize ideas for improving cultural competence among staff and better tailoring services to diverse populations. Engaging staff from diverse backgrounds in the brainstorming process helps ensure that the needs and perspectives of diverse communities are represented.

·       Flowcharting can map out the steps in a process from the perspectives of clients from diverse backgrounds, focusing on identifying areas where cultural responsiveness is lacking. As a result, flowcharting can help identify gaps in care and test targeted improvements to ensure that services are tailored to the unique needs of diverse populations.

·       PDSA Cycles can test new approaches to promoting cultural competence and addressing disparities in care. In addition, teams can use data from PDSA cycles to evaluate their effectiveness and make informed decisions about scaling up or modifying their approach.

In addition, we’re exploring ways that the NIATx approach can help organizations align their processes with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Learning about the CLAS standards is one thing but implementing them presents a challenge.

NIATx Change Leader Academy/CLAS Standards

In April 2023, we’re offering a one-hour session titled Using NIATx to Strengthen Your Workforce: Implementing CLAS Standards for Recruiting, Hiring, Retaining, and Promoting (RHRP) Staff. This interactive training will teach participants about the CLAS Standards and why they’re vital to improving care, reducing disparities, and advancing health equity. We will also cover strategies for implementing the CLAS standards, including the important role of the change leader. This session is part of a five-part series designed to help participants prepare for a follow-up NIATx Change Leader Academy.

The integration of the NIATx model and the CLAS standards provides a powerful framework for promoting cultural responsiveness and equity in behavioral health services. By emphasizing the importance of a systematic approach to quality improvement and cultural and linguistic competence, this approach can help ensure that every step of the process is tailored and measured to meet the unique needs and preferences of diverse populations, whether they are a client or an employee. This can lead to better patient outcomes, improved workforce retention, and ultimately, a more effective and equitable healthcare system.

The NIATx model continues to evolve in response to the changing behavioral health care landscape. As new challenges and opportunities arise, the model adapts and expands to incorporate the latest research and best practices. Through ongoing innovation and collaboration with stakeholders across the behavioral health care landscape, NIATx is helping to transform the way we deliver care, improve outcomes, and promote health equity for all individuals.

About the author:

Alfredo Cerrato is the Senior Cultural and Workforce Development Officer for the Center for Health Enhancement Systems Studies at the UW–Madison. He currently manages Intensive Technical Assistance projects for the Great Lakes ATTC, MHTTC, and PTTC. He is a subject matter expert and trainer of trainers for the National Standards for Culturally and Linguistically Appropriate Services (CLAS). Alfredo specializes in the relationship between the CLAS Standards and process improvement, focusing on organizational change, cultural communications, worldview dynamics, and conflict resolution. He has 25 years of international relations experience and has conducted advocacy, policy, and disaster relief work in collaboration with multiple governments across the globe.

ATTC's Pearls of Wisdom: Centering marginalized voices in the change process

By Maureen Nichols, South Southwest ATTC, Jessica Jarvis, South Southwest ATTC, Dawn Tyus, African American Behavioral Health Center of Excellence, Susie Villalobos, National Hispanic and Latino ATTC

In 2021, following the promotion of the ATTC Network’s new core curriculum on stimulants, the South Southwest ATTC received a request from our region’s substance use treatment and recovery providers to develop more resources for family members of people facing challenges from stimulants and other substances.

As the team planned for development of a new resource to serve this need within our region, we chose to adapt the traditional ATTC approach to product development.

In addition to reviewing existing resources and evidence-based practices, we looked to the Seven Principles for Developing Equitable, Recovery-Oriented Behavioral Health Systems a framework developed by Ijeoma Achara-Abrahams, PsyD of Achara Consulting.

Dr. Achara presented these principles at a three day interactive Recovery Oriented Systems of Care Equity Summit. The summit was co-facilitated by Dr. Dietra Hawkins and cohosted by the African American Behavioral Health Center of Excellence, the South Southwest ATTC, the Northwest ATTC, the Great Lakes ATTC.

Seven Principles for Developing Equitable, Recovery-Oriented Behavioral Health System

  1. Ensure that the voices and experiences of those who have been most marginalized in your system are leading and are integrated in all aspects of the planning and change process. 
  2. Identify goals that build on one another. 
  3. Keep bringing people back to the shared vision, goals, and performance indicators. 
  4. Continuously over-communicate. 
  5. Constantly challenge stakeholders to push beyond individual-level solutions. 
  6. Don’t wait for a critical mass of individuals to feel a magical level of urgency; keep moving forward with the strengths and resources you’ve got today. 
  7. Continually review your progress and celebrate your successes.

We partnered with the National Hispanic and Latino ATTC, the African American Behavioral Health Center of Excellence and local community partners who have experience working with individuals and communities that historically experience inequitable health care. We formed a workgroup and strategized adaptation of our traditional SSW ATTC development processes to meet these principles. 

Workgroup conversation resulted in the following key takeaways.

1. It’s more than a product or a training

       There is a significant lack of support for families in our treatment and recovery ecosystems and in their natural communities.

       Once families have the information provided through the resource, what ongoing support and resources are available for them in communities?

       How can we empower individuals and families in the communities as healers, and build a workforce that support families?

2. Importance of community engagement

       Who is our audience and what are they looking for?

       We need collaborative governance as we create.

       We must acknowledge and validate that many communities have a reason to distrust systems designed to help, while proactively working to build trust in communities

3: Everything is local

       Even if we design culturally responsive content that is tailored to specific populations, communities are diverse, and each audience is different.

       A product needs to include processes for facilitators to gather local community input and support for adaptation.

Initial Actions

Reflecting Principle #1, the workgroup began with a series of listening sessions with family members and loved ones of people using substances. The purpose of these sessions was to gather information to better understand:

Family members’ experiences supporting and seeking support for their loved one

What questions family members have about supporting their loved one

Who or what is providing support for family members 

Unmet needs for support for family members

Since this was the first time our regional ATTC included individuals with such lived experience as partners in our development process, we utilized a series of specific new strategies:

  • We recruited facilitators with deep community connections (including peer recovery support specialists) to outreach to family members and loved one who might be interested in contributing their lived experience and expertise to the process. 
  • These facilitators were part of communities that traditionally have not had a voice and representation in health care systems, including Black, Hispanic, and Indigenous communities. 
  • We began outreach in three of the five states in Region 6: New Mexico, Oklahoma and Texas, where we had the strongest community collaborations. 
  • We paid both the facilitators and the community members for their time and expertise. 
  • We provided support and training to the facilitators around the process of facilitating the listening sessions. 
  • We established a schedule of 20 online listening sessions, with plans to facilitate six sessions in Spanish, for up to 108 people, with a timeline that fit the parameters of our annual ATTC workplan. 
  • We conducted an online follow up survey and phone calls with all listening session participants to obtain their feedback on the process and its impact.

The work group and facilitators conducted outreach to community members in May and June 2022, yielding 38 registrants across the listening sessions in July 2022, 23 of which ultimately attended a session.

Family Member Voices

Family members openly shared their experiences, their concerns, their hopes, and their needs.  Some common themes arose outlining the complexities they face in navigating systems, stigma, and self-care. These themes are outlined in greater detail in the project report.

Process Lesson Learned

Reconvening to reflect on the process, the workgroup identified some key lessons lesson learned. 

  1. In our efforts to meet internal deadlines for product development, we failed to fully work together with our community facilitators in Oklahoma. When there was no participant online registration for the Oklahoma sessions, we made an internal decision to not move forward without consulting with our partner community facilitators. As a result, we excluded those facilitators, who were from the Indigenous community and also had lived experience as family members, from participating in the listening session and having their voices heard. This repeated a common harmful experience for them personally and as a community of being discounted and ignored within a health care system.
  2. The traditional ATTC product development timelines do not work well for this process. In order to maximize and diversify participation (and maximize the relevance of any subsequent product), we must allow more time to build deep community connections, establish trust, and conduct cycles of action, reflection, and improvement. 
  3. Conducting outreach and listening sessions online increases access for some and limits access for others. Ideally, in-person outreach and sessions would also be offered.
  4. While the purpose of the listening sessions was to collaborate and include the expertise of the lived experience of community members, an unintended, beneficial consequence of the listening sessions was informal mutual support among the participants, who provided emotional support and shared resources with each other.

What’s next?

  • Establishing deeper community connections through outreach. 
  • Hosting additional, in-person listening sessions with community facilitators and family members. 
  • Conducting cycles of action, reflection, and improvement to further strengthen the new product development process. How can it become more truly collaborative with the community partners who have contributed so far? 
  • Developing and piloting resources to meet the community need. 

The full report on the listening sessions can be found here.

We’d like to acknowledge the contributions of members of the Cultural Family Resource project workgroup:

African American Behavioral Health Center of Excellence

Dawn Tyus, PhD, LPC

National Hispanic and Latino Addiction Technology Transfer Center

Maxine Henry, MSW, MBA

Susie Villalobos, Ed.D, M.Ed., CCTS-I

South Southwest Addiction Technology Transfer Center

Beth Hutton, MS, LPC

Jessica R. Jarvis, MSSW

Raynon McGee, MASM

Maureen Nichols, BA

Subject-matter experts

Johnna James, Chickasaw, Ed.D. Candidate SNU

LaNisha Jiles, PSS, RSPS, TOC, PRSS

Shuniqua Ortiz, MA, LPC

Timothie Smith, C-PRSS-Y,S

Ruth Yáñez, MSW, LMSW