Okay, we're going to wait just about a minute longer to let people get in and then we'll start. Okay, we're going to go ahead and get started. Good morning everyone. Thank you all for joining us this morning on behalf of ORN, our ORN partners, AAAP, ATTC, Columbia, and KAI, in coordination with SAMHSA and OTAP, I would like to welcome you all to the TOR webinar series. This is the third presentation in this series, and today we will be talking about culturally responsive care and clinical adaptation. This webinar series is designed for Tribal opioid response grantees, but all are welcome to join and participate in the session today. My name is Kelly King, I serve as a technology transfer specialist for the ORN in the Mountain Plains and South Regions, and I'll be helping to facilitate this session today. We will begin this presentation by opening in a good way. It is my honor to welcome Ken Atanover to the meeting today. So Ken, I will pass it off to you. Thank you. Good morning, everybody. Ken Hanover, Round Valley Indian Tribes member. As part of my morning routine when I wake up in the morning and get going, I like to smudge and say a prayer. I usually look on the things that I'm grateful for and thankful for that day to get me started in a positive way. After that, I like to read out of my little book here, 365 Days Walking the Red Road. Well, this morning's Cherokee blessings seem fitting for this time of year. So I'd like to read that to you guys to open us up this morning. It says, May the warm winds of heaven blow softly upon your house. May the Great Spirit bless all who enter there. May your moccasins make many happy tracks in many snows, and may the rainbow always touch your shoulder. Oh. That's a beautiful little prayer. I like that. I'd like to share it with you this morning. Thank you. Thank you, Ken, for that wonderful opening. Okay, so for the logistics, we'll begin today with an overview about the response network, and then transition to our presentation for the day. Once that is complete, we will have a discussion around TA requests. The chat box will be open during the session, and we will aim to answer all the questions once the presentation is complete. At the end of the session today, we will have a brief survey and kindly encourage your participation in that. So working with communities, we do want to acknowledge that today's webinar is funded by SAMHSA. We do have ORN and SAMHSA staff on the call today, as well as leadership and project officers. The opioid response network is funded by SAMHSA to provide free training and consultation to communities across the country. The ORN can assist with requests related to opioid and stimulant use, prevention, treatment, recovery, and harm reduction. The ORN has a pool of over 300 consultants that help provide training and consultation for TA requests. The ORN also has designated teams spread out across the country who provide local expertise to help fulfill TA requests. And this is really important. Each state and territory has a designated team led by a regional technology transfer specialist who is an expert in implementing evidence-based practices. The TTS is your point person. So requesting technical assistance. Our goal is your goal. ORN accepts requests for education and training via a short submit a request form at opioidresponsenetwork.org. ORN responds within one business day. So after you submit a request, we respond within 24 hours to set up a call and discuss your needs. All education and training is locally relevant, culturally specific, and tailored in response to the requester to meet the specific needs of the individual, community, or organization. Here is a map of the different regions that we cover. So we are broken up into five regions. And there is a duo that is located across the five regions displayed on the map that help fulfill TA requests. Here are the technology transfer specialists that provide TA to each region. And they are all part of the Indigenous Communities Response Team. Please take a look at who covers your region as these are the people who will be fulfilling the TA requests that come in and will be your primary contacts. This next slide is a picture of the Indigenous Communities Workgroup. The Opioid Response Network has created this workgroup. These are individuals who have experience and expertise working in and with Native communities across the nation. Regional TTSs are able to reach out to this workgroup for guidance on any TA requests they need assistance with. Now it is my honor to introduce our speaker for today's session. Dr. Anitra Warrior is an American Indian child psychologist and owner of Morning Star Counseling. Dr. Warrior has provided clinical services to Native children and families throughout the state of Nebraska for the past 15 years. Morning Star Counseling has seven locations and partners with multiple school districts, colleges, tribes, and organizations to support the healthy development and mental well-being of children and families across the state. Welcome, Dr. Warrior. Thank you, Kelly. It's a pleasure to be here and thank you all so much for attending today's presentation. I would like to quickly add that as we go through this, this is really introductory. We have a limited amount of time to cover a great deal of information as we talk about how we adapt clinical services for the Native population. So we're just going to basically be skimming the surface as we go through this. And if there are additional questions that you have after the presentation or if there's more information that you would like from me or from ORN, you could just follow up with ORN and they have my contact information. So again, it's very introductory. So just wanted to make sure that I shared that. So Kelly gave an introduction of who I am. And I'm from the Ponca Tribe of Oklahoma. And something that is really important to me in sharing why I'm in this field and why I'm really passionate about providing information on how we adapt clinical services comes from my own experience as someone who was receiving clinical services. Several years ago, in my early 20s, I had lost my oldest child. And I had met with, throughout that process of grief, you know, and it being very difficult as someone who was young, limited coping skills, I started working with a therapist. And I actually worked with more than one. And what was happening during that time is any references that I made to culture, to my culture that was specific to my tribe, those would become pathologized. And what I mean by that is that if I would share something about how we process grief or things that were happening within my home, it would often go back to what hallucinations I was having. This is where I'm talking about pathologizing my culture, pathologizing our beliefs. And that counseling space that was supposed to be a space for healing was anything but. It was actually more damaging to me and my healing and my growth because it made it seem like there was something wrong with me because of my beliefs. So from there, that's when I moved into this field. And it's, again, just a passion of mine to be able to share this information because it really can impact the overall healing and well-being and just the safety of the clinical setting. So thank you for letting me have the time to share that and just introduce myself a little bit more and tell you what really drives me in this work that we're providing. So today, we have a few areas that we'll cover. And, again, it's going to be introductory because I know we have limited time. But we're really going to be looking at some factors that contribute to Native resistance to behavioral health supports. And this will be across communities. We're going to look at the differences between Native and westernized worldviews and treatment approaches. And so we're going to break that down a bit, even looking at how supervision is provided because there are multiple levels to this when we're talking about the differences in worldviews. Then we're going to take a look at some culturally-based protective factors. I think no matter what we address, it's always important. This is just vital for us to be able to address this and recognize those strengths that are within our communities, that are part of our culture. We always have to be able to recognize those and bring those into the work that we're doing. And then we're going to look more into essentially a model that we're proposing in terms of how we can make these adaptations. But it's really about what we take into consideration as we make these adaptations into an overall clinic, not just for those that we're serving, but also for general operations, for supervision, for the supervisee as well. So a lot of information that we'll cover in a short time. Next slide, please. Thank you. So what we know right now is that we have a lot of resistance to treatment, okay? And that doesn't come from nowhere. There are reasons to this as to why there is that level of resistance. We're going to see this in Native communities and African-American communities, in rural communities as well. There, again, are many, many reasons that contribute to that level of resistance. What we're going to start off by recognizing is what has been found in the research in terms of some contributing factors to the resistance to treatment. So let's start off with accessibility. And I really do encourage everyone to keep these three terms in mind as we move forward and as you think about how services are delivered, how they're promoted within your communities. So with accessibility, what we're going to be looking at is how many people actually know this service is available? How many people know the providers? And how are we actually going to be getting there? When we think about our rural locations and some of our reservations, that can be in remote areas. If we're having to travel in or we're having to worry about the service delivery area where we can receive these services, sometimes transportation can be an issue. Or even just the price of gas. Do I have a consistent or a vehicle that will be able to get me there? And if so, what does this mean in terms of childcare? Or I remember in one situation where we were serving a reservation in a rural community, and the neighboring reservation to this rural community was across state lines, and they would load up a van of students and drive to the clinic. And even though each of those students only had a one-hour session with us, they were missing a full day of school because of issues with transportation. So these are some of the things that we had to work through. So accessibility can be a significant challenge. And then when we also look at financing and how are these services going to be paid for when they're not grant funded or available through IHS? So some things for us to keep in mind when we're talking about accessibility. And then we have acceptability. That's a huge one for us. And this is going to be looking at stigma, anonymity, dual relationships, and then also outsiders. Outsiders coming into our communities with their own worldviews on what healing should look like. What the process, the treatment process should look like based on what we've learned in school. And that can be a challenge. The other piece with acceptability, as we all know, are the high rates of stigma that are associated with behavioral health services. The other piece is going to be anonymity. So many times we have our clinics that they are known that these are the behavioral health clinics. And when we're thinking about rural communities or reservations, what we can see is that, okay, so-and-so's car is over there. That's really going to limit what it looks like in terms of anonymity. Very important things for us to keep in mind. Now, when we talk about dual relationships, this is where we can really see us pushing the boundaries. And something that I really promote is the acceptance of dual relationships within our tribal communities and just actually overall in Indian country. With this, we do have to be very intentional about what that relationship looks like and making sure that it's not going to bleed into the actual clinical session itself. So I'm part of a-and I'll give an example of this. I'm part of a talking circle in the next town, which is a pretty large urban area. We're also one of the only native-owned behavioral health clinics. So even though I'm a part of this talking circle, I will share personal information. But there are other people within that talking circle who also want to receive services from me. I can't allow that to happen because as I'm sharing personally, I don't want to risk any of my information coming into the session for that relative. So that's the way that we have to really manage what dual relationships look like. The other piece in this, though, is when we're talking about a reservation, rural areas, Indian country in general, we know that we're all related in some way. There's going to be some way that we're going to have a relationship. So again, it's going to come down to management of that and really challenging what that would look like to where we're not jeopardizing our licensing by any means. But we're also recognizing the power of relationships, which is an evidence-based practice when we're talking about relationship. So really want to encourage you all to think deeply and spend time in that when it comes to dual relationships and how that can impact acceptability of services. The other piece that is the third factor that had been found in research through HRSA has been availability. Now, that's challenging when we're talking about what does the workforce look like. Right now, and especially since the pandemic, we've really had a shortfall in terms of the workforce and what providers are available. So even prior to the pandemic, when we're looking for specialized services, we could be looking at a wait list of two to three months. That is still happening, but it's even more challenging now because we don't have as many providers available. So these are going to be another areas to take into consideration when we're thinking about resistance to treatment. The reason I think this is so important for us to recognize when we're providing clinical services is because if we're not aware of these factors that are contributing to that resistance, it's going to be very easy to put the blame on the relative who's seeking services and make it seem like this is a characteristic of them rather than a characteristic of the community or rather than a characteristic of society and what we're dealing with. So we want to make sure that we're not attributing these factors to the individual who's trying to receive services. We want to know where these factors are coming from, and they're often from the community, which can really be out of that individual's control. Okay, next slide, please. So we're going to go a little bit further with the resistance to treatment. This one is going to be specific to Native Americans or American Indians, and I am going to read directly from the slides. This is really important to me to be able to do that, and the reason that I do read directly from the slides is, one, because people process information differently, and whether this is vision, whether this is dyslexia, there can be so many factors. So just wanted to give you the heads up that I will be doing that as we're progressing through the slides. So for historical trauma, it has been described as complex and collective trauma experienced by a group of people that share identity, affiliation, and circumstance over time and across generations. That's the key point that I want to highlight from this particular statement is it's over time and across generations. We're going to go into a little bit more detail on that here in just a minute. Historical trauma has implications for both mental and physical health of individuals that lead to inequities that may be observed centuries later. Centuries later. Historical trauma, unresolved grief results from the loss of lives, land, and vital aspects of Native culture promulgated by the European conquest of the Americas. Some powerful statements here that are referencing historical trauma and the impact that we have. Now this may be a little bit difficult to see, but we have some words here listed on the picture on this graphic with this Native male. And it says anxiety, depression, panic attacks, PTSD, struggles with self-esteem, addiction, and substance abuse. These can all be tied into historical trauma. And the way that that can happen can come in many different ways. But I'm going to give one example for us to take into consideration. Excuse me. So one example that I want us to take into consideration is as we think about boarding schools and what some of our relatives have experienced with boarding schools. When we think about the level of abuse that was there, the level of shame that accompanied that. Excuse me. Let me have just a second here. Sorry about that. So the shame that accompanied that, not because this was something that was already within those young relatives that were going to boarding school, this was something that was forced upon them. Okay. So we have abuse. We have shame. We have depression. We have fear. What we can expect to see from our relatives is going to be that level of hyper arousal to where they're constantly living in this fight, flight, freeze mode. What can happen for our relatives is that we can get stuck in that. If we're not having a way to process that, if we're not having a way to heal from that, that can be a way that our body just responds. We're going to see more of the cortisol being produced. It's going to be really difficult for us to really focus on our executive level of functioning, which is going to mean just our decision making. What's going to happen is we're going to be really focused on survival and we're not looking at how we can grow in terms of problem solving, comfort, love, all of those when it comes down to survival. These practices that we've had to learn to survive are then passed on to our other generations. And then what we could call maladaptive behaviors have then been reinforced as they're being shared across generations. Just as I mentioned in that first bullet, this is happening across generations. So it's going to be that intergenerational trauma that we're seeing. That is how historical trauma can directly impact us in areas of anxiety, depression, panic attacks. And as we think about the stressors that our people experience, that can have a direct impact even in utero. So if we're pregnant, if one of us are pregnant and we're going through these high levels of stressors, everything that we're experiencing is going to be shared by that baby as well. What can happen in that sense is that child may be more likely to experience PTSD or depression. So this can be almost like it's encoded in our DNA, but I want to be very, very strong in sharing that this does not mean there is a guarantee that historical trauma is going to cause this because just as those challenges are passed down, so are the strengths. We're also going to have many strengths that are going to be passed down from generation to generation based on what we've learned. And we'll go into some of those in a couple of slides. Let's go ahead and go to the next slide though. And with this one, we're going to go ahead and transfer now to looking at overall clinical work. This image in my mind speaks volumes. And the reason why is because what we see here is what we've probably all heard of as we're doing our grant applications, as we're going through our trainings to provide behavioral health services, as we're just operating our clinics in general. What we're always going to hear about are evidence-based approaches. I wish I could see everyone because I would ask you to raise your hand if you heard that term evidence-based approaches. We write that in our grants. This is something that is pushed, and of course, in our programs where we're receiving the training, but it becomes, thank you, I see that, but it becomes so overwhelming that this is glaring. This is what we're going to focus on are the evidence-based practices. When we do that, we minimize the approach of clinical interventions that are going to be uniquely tailored to those communities. We're also going to minimize the power of the traditional healing approaches. What can happen is we're almost going to be afraid to even bring in these traditional healing approaches as we're going through our training. This can have a direct impact, especially when we have providers who are unaware of traditional healing approaches. That can almost be a significant challenge in terms of incorporating this even into the treatment plan, incorporating this into the healing. That can be a challenge if it doesn't align with how I was trained for evidence-based approaches. That six-week course that I went through for this particular type of therapeutic intervention, if it's not appropriately adapted, this is what we're going to see. All the power going to that evidence-based approach without recognizing the power of unique clinical interventions and the extreme power of traditional healing approaches. We'll talk a little bit more about some of those approaches. Again, we have limited time, so we're not going to go into great detail on those, but I do want to make sure we have a couple of examples of how we'll go through that. I think that will also come later in the presentation. We can go ahead and go to the next slide. When we're looking at those worldview and treatment approaches, there are several things we want to keep in mind, and we're going to move through quite a few areas in this. I think actually we have about four different areas that we're going to go through with a model that we'll be proposing a little bit later. What we want to start off looking at are going to be the systemic and societal concerns. We've already talked about evidence-based approaches and how unless those are clinically adapted or we have clinicians who are really familiar with culture, with the power of those protocols within the culture, we're not going to see those integrated at the level that they can be and the level that they should be, depending on the population that we're serving, as well as the individual level of enculturation. With our clinical interventions and traditional healing approaches, we want to be able to look at how to integrate traditional healing approaches within sessions and or our treatment plans. We also want to make sure we know what are going to be some specific examples of how this can be done. The one example that I want to go ahead and use is the sweat lodge. I go to sweat, and the process in there and the way that I can interpret it is very familiar to cognitive behavioral therapy. That's a really big evidence-based approach that is always talked about as one of the gold standards. It can be used with trauma and just so many different areas. Cognitive behavioral therapy is happening. These are the components of CBT are already happening within sweat. Let me give an example of that. When we go into sweat, we are really focusing on what our thoughts are. We're engaging in prayer. There's a level of thought stopping that's happening. There's a level of autonomy in terms of what we're asking for in that environment with the community, with those that we're praying with, our brothers and sisters in prayer. That is also creating a safe space for calming. During that time, we're able to address traumas in a safe space where we're reprocessing that information. There are the songs that are also helping us process that information. As you go through this, what's happening is, remember how I mentioned that basically like that emotion brain, we're in that fight, flight, freeze. When we're in this, in sweat, we're able to pull back from that. We're able to regulate our systems, our emotions, and we're able to really focus on what's happening up here. That's all part of the prayer. There are so many different calming skills or coping skills that are learned throughout that approach, even with our movement. Not everyone moves. I know for me, as I'm in sweat, one of the things that I'm always doing is I rock. No one sees that because it's dark, but that's also part of my calming strategy. That is learned there. There are so many coping skills that are going to have a direct impact on our brain. Through that process, we're developing those, or we're changing those neural pathways that are giving us healthier ways to think, healthier ways to cope, but if you're not familiar with that process, you're not going to know how to incorporate that. In my treatment plan, if I'm writing this, I would not have to say that I'm assigning or recommending sweat two times a week. I wouldn't say that. I would still say that we're utilizing interventions for cognitive processing and cognitive coping. That would be a way that I could describe those things that are happening within sweat. That's just one example of how we can utilize our culture within that, but if the systemic and societal norms are not adjusted, if our clinicians are not going through an orientation to our tribal communities, they're not going to know to be able to use these strengths to help those individuals, those relatives with their healing. When we think about these systemic and societal norms, the other piece that we want to keep in mind is going to be attendance, outreach, language, and ethical guidelines that are conflicting with culture. Some of the examples that I provide here include the no-shows and the late starts, being present in the community, participating in events and gatherings, having multiple roles in rural communities, which we talked about that with the dual relationships, as well as gift-giving. Each of these we could spend a lot of time talking about, but with no-shows and late starts, I think that's really important for us to keep in mind because what we have to focus on, rather than just attendance or timeliness of showing up because, well, let me finish this statement. What we want to focus on besides that is the power of the relationship, and is this relative continuing to come back for service? What can happen if we're not paying attention to these societal norms is we can interpret that as a form of resistance because this individual continues to show up late for services. No, that's not really the case that's happening here. Or even the no-shows, having a recognition of what's happening within the community, maybe the traumas that are experienced in the communities, the various events that take place in the communities. So you really have to have that level of flexibility so you're not placing any type of judgment on the relative who's being served. The other piece is being present in the community and being able to participate in those events that are happening. What this does is also helps us go back to that relationship. So we're not coming into the community to tell you how to heal. We're going to be a part of that. We're going to be a part of this all together. That relationship is going to be that strong to where it is not limited to just the clinical setting only. I'm not going to go through the multiple roles again, but also with gift-giving. This is a huge one, especially within Native cultures. Something that I'm always happy to share is that this is a part of who we are. We give when we're grieving. We give when we're honored. We give when we're asked to do something. That is a part of our culture, our identity, a part of who we are. When we refuse those gifts, it's essentially like refusing the relationship. That's really important. And gift-giving can happen both ways. So for example, we offer trauma-focused cognitive behavioral therapy. This is specific for children. With this therapy, once the relative completes the full model based on their time, but once they have completed this model, we actually have a graduation ceremony. They're able to invite whoever is a close part of their life that has familiarity with what they've experienced. We give them a star quilt. We feed the family. That's a part of our process in recognizing them, in honoring them and the work that they've done. This is huge for us and not something that you would typically see across clinics that haven't had that adaptation in terms of challenging the Western worldview of operations for a clinic. The other piece is with the system resistance to cultural humility. This is something that we can see where part of it can come down to licensing. I will bring that up probably multiple times. But when we're challenging some of these, that can go against some of what the protocols are or the principles and guidelines that we follow, for example, like with gift-giving or with dual relationships. There is that resistance from the overall administration at times to be able to do that. That's where we see that resistance to cultural humility, which is basically saying this way is the right way. So we want to be able to expand beyond that. Next slide, please. So with the cultural protective factors, this is going to be huge as we recognize this. I would really encourage everyone to, if you're a clinician who provides services, as you think about the strengths that you ask about in your intake, as you think about your questions regarding culture, how much of this is integrated throughout, it'll be really important to recognize this not only for that relative that's receiving those services, but also how does this impact their family? What can we incorporate from their strengths into the family as well? How are we seeing that? How are we conceptualizing this? So I have a couple of different sites here that I'm referencing in terms of cultural protective factors. We have identification with culture, family, a connection with the past, traditional health practices, adaptability, wisdom of elders, and spiritual orientation. All of these are considered protective factors. Protective factors against depression, against loneliness, against isolation, against substance abuse. This other site here from the 2017 article references enculturation, and this is going to be our level of involvement, our level of engagement with our tribal practices, interconnection, tribal language, ceremony and powwow, spirituality, and ethnic identity. What I want to highlight specifically about these cultural practices, the way that this was all measured, the way that this all came about was through this large lit review. I think there were over 3,000 articles that they may have gone through for this particular study. And what they were able to find was that specific cultural protective factors could impact specific areas, including educational attainment. I already mentioned substance abuse from the other site, but there are certain protective factors that have a direct impact on this. There are many more that were listed. I didn't go into full detail from the article, but I do really encourage everyone to take a look at that and see the different ways in which cultural protective factors can enhance well-being in so many different areas of our lives. Next slide, please. Okay, so now we're going to go really into the clinical adaptation. We're going to have a few slides going through this, and the map here may be a little bit challenging to see with some of the smaller writing. What I want us to focus on are going to be those major headings that we have here. So we have systemic and societal norms, which we've talked about already. We have protection of our providers, supervision models and adaptation, and then clinical adaptation. What you'll see in this model is that this is constantly evolving. So it's not going to be systemic and societal norms is number one. You have to address that first. It could be starting with protection of providers, but they are all related, and we have to continue to be evaluating each of these areas as we're providing appropriate and culturally responsive services to our communities, to our tribal communities, to our urban communities. We want to make sure we're taking a look at how are we addressing each of those areas. The reason that we see supervision as so important in this model is going to be the interplay of privilege and oppression. This is going to be about the power differential. The supervisor is someone who's going to be evaluating the clinical service. They're going to be evaluating that particular provider. That supervisor will also be an experienced clinician, and they are going to have authority over the trainee. This one can be tricky because they do have so much authority as a supervisor. What we want to make sure we're encouraging here is that they're taking a look at those conflicting worldviews. Are they conceptualizing or understanding this case at an individual level or at a collective level? An example I'll give is a female relative who was receiving clinical services from a non-Native provider. As this individual talked about her role within her family, it was seen as something negative, and it was seen as a level of enmeshment, and it really came from that individual perspective rather than as a strength within a collectivist society. That's the differences in worldview. That's why this is so important for us to recognize those changes because we just pathologized something. We just made something that was a strength. We just made that a negative. We just made that a piece of treatment now that we may have to focus on to pull this person away from her family because in our individualistic view, she's enmeshed. Those are things that we have to challenge from our supervisors as well, and our supervisors have to be open to that level of thinking as we're talking about clinical adaptation. This is going to lead us into protection of providers. For our clinicians, what we can see, specifically for early career clinicians, we can see those microaggressions. We can see high levels of burnout. That burnout can also happen to our seasoned clinicians as well, especially since the pandemic, but burnout is also really something that we have to pay attention to. Secondary trauma. This one is really important for us to recognize, especially if we have clinicians who are from those communities. If we're experiencing grief in one of our tribal communities, that's going to be a form of collective grief. That's not just going to be the one individual. When we lose someone in our tribal communities, that has a ripple effect throughout. That's impacting our nation as a tribe. It's really important for us to recognize those things. In addition to the secondary trauma, we also want to pay attention to the level of isolation that our clinicians can face, specifically as native providers. That's huge. When we're thinking about the way the training has happened for us, who we're typically going through these classes with, there can be this high level of isolation that happens for clinicians. When we're talking about a collectivist society, that level of isolation can have a direct impact on what clinical work looks like. Next slide, please. I think that was a little bit out of order. Actually, if you want to go ahead and go back to that larger one, I can spend just a little bit of time reading through this. What you'll see in the systemic and societal norms is what we've started to cover, the conflicting worldviews, understanding privilege, recognizing the role of historical trauma, and also recognizing cultural norms versus larger societal norms. We've already gone through some examples of those. The other piece is going to be the protection of providers, which we had started to talk about with microaggressions, secondary trauma and burnout, power differential. The other piece that's not highlighted in that previous slide was the stage of development. I did talk about it being for early career professionals and a little bit of the difference between early career and seasoned, but that's also really important for us to keep in mind for our clinical supervisors, and even who is being assigned to whom to provide those services. When we look at supervision models and adaptation, we're going to be looking at basically what we're saying is decolonizing or re-indigenizing supervision. We'll go through that a little bit more in the next slide. We recommend looking at various models of supervision. Depending on the level of training that you have, a lot of programs do not require that you have any classes or any courses or any training on supervision. This is really important for us to keep in mind because that supervision can have a direct impact on what clinical services look like. We want to make sure we're familiar with various models of supervision that are going to align with our clinic, as well as the population that we're serving. We look at clinical adaptation, and this is going to be talking about the policies and procedures of the clinic, because it really needs to start at the top. We need to be able to see all of that integrated at the top, as well. We want to look at language. What language are we using? The clinical aesthetic, which would also be referencing the clinical environment, the level of cultural integration, and the clinician to relative, what that relationship looks like. Let's go ahead and go to the next slide, Kelly. Thank you. Okay, so we're going to talk a little bit here about the therapeutic models. This is also a piece of this overall model with the supervision models that I had referenced. There are so many out there that are available that can really help with guiding the work that we're providing within our clinical services. With clinical supervision or consultation, this is huge because this can really help reduce the onset of burnout, secondary traumatic stress. It's going to come into play for that protection of our providers. We have the person-centered approach, where with that approach, we're really going to see that this clinician is going to have the skills necessary to do problem solving, to work through what's being presented. With the cognitive behavioral model of supervision, it's going to be more agenda-based. We're going to have specific tasks. We're going to have specific things that that clinician is working on. Then we have the discrimination model. With the discrimination model, with this model, what we're looking at is at times during our supervision, we're going to be a consultant. At times, we're going to provide that direct supervision. At times, we're also going to fill that counselor role. For me personally, I am fond of the discrimination model because of everything that comes into the counseling setting. That removes that power dynamic. When we're talking about decolonizing training, what I want you to hold on to from that particular statement... Oh my gosh, I'm sorry. I'm not coughed until I started the presentation. What I want you to take away from that statement with decolonizing training and supervision is we are going to remove the hierarchy because we're all in this together. This is about relationship. This is about learning together. This is about serving individuals, families, relatives, communities. That hierarchy can really open the door to more harm, harm for that clinician and harm for that individual, the one who's receiving services, the relative who's receiving services. That's why I'm fond of this discrimination model because it really opens the door to, let's let this clinician be a person. They're not a blank slate. They're going to come in with history. They're going to come in with knowledge. So is the relative that we're serving. They're going to come in with their history. They're going to come in with knowledge. I can't sit up here as the supervisor with that level of hierarchy thinking it's my way or no way. We really want to integrate and pull from that collective wisdom that comes from the counselor as well as the relative who's receiving services. We also want to look at the therapeutic models and how they're being put into the sessions. When I say that, what I'm talking about in addition to how we're incorporating culture, which is going to be huge, the biggest piece of this, how we're incorporating culture, the other piece that we want to look at is what are we measuring? How are we identifying what change looks like? And is that based on what research tells me this change needs to look like? Or am I looking at change in terms of what this individual needs? Am I looking at change in terms of what this relative needs that fits within their culture, that fits within their family? That would be the piece that I would say we always need to challenge. We always need to continue to assess when we're talking about the therapeutic models. And remember how I mentioned the big, overarching umbrella of evidence-based practices. They're good, great. We know that they make an impact. There are so many pieces of our culture that have well beyond the time that these studies had started, we had already been incorporating for our wellness. Really important for us to keep that in mind. A couple of models that I'm highlighting today are the trauma-focused cognitive behavioral therapy, which has been adapted for American Indians and Alaska Natives, as well as parent-child interaction therapy. You would be able to Google these or look at nctsn.org, and I can put that in the chat here in a minute, but the National Child Traumatic Stress Network would give you more information if you were interested in training in these. But these are really exceptional in terms of integrating culture into the overall treatment model and utilizing those cultural practices in a way to where we recognize that we are seeing lower levels of emotional dysregulation. We're seeing higher levels of cognitive processing. We're seeing higher skills when it comes to cognitive coping. Really important factors for us to keep in mind when we're referencing culture as that intervention. Next slide, please. The other piece that we look at when we're talking about adapting our clinical practices, okay, we want to look at the clinic environment as well as the policies and procedures. So, this includes, one, the clinical environment, which is going to be really, how does the clinic look? When we think about, remember I mentioned the boarding schools, so we can think about these sterile environments that we've been exposed to. What we want to be able to offer in these settings is a place that's reflective of the community. We can see people from the community working in our clinics. We can see artwork from the community in our clinics. We can see that everything about me as a Native person is welcome and embraced in these clinics. That's how we change the clinic environment. We also want to see that representation of staff. As I mentioned, our community members should be a part of our clinics and the services that we provide because we're part of that community, right, that comes down to the relationship being that reflection of the community. When we talk about clientele, we really want to be cautious on the language that we're using and any biases that can come into play. This one can be a really challenging one to address because there can be many areas that can go from one tribe to the next. One of the things that maybe you've noticed is I've talked about those who are receiving services, I've referred to them as a relative. The reason we do that is, one, because that's our belief as Native people that we're all related, but the other piece is recognizing the power of that relationship. We have the honor of being in this clinical relationship with this individual where we are part of their healing journey. We're part of that. How could we not recognize them as a relative by allowing us to be a part of their life? There's so much power and collective wisdom that can come from that relationship when we recognize them as relatives. That's part of the languages or the language that we can change. So, being able to utilize language from a community, that's going to be appropriate in this area. Different events, depending on what community you're in, what a hand game may be called. If those are events that are happening regularly, use the correct language there. Don't force your own language into this. We're not saying to not be authentic, to not use things that are true to you, but we also want you to be part of that community. Then, when we talk about policies and procedures, we want to look at the operations. We've already gone through supervision in quite a bit of detail, but when we're talking about operations, we really want to think about how are we responsive to the community? Again, as we've mentioned, we're not coming in to tell the communities. We're not coming in to tell them, this is what you need to do to heal. We want to be part of it. Again, tapping into that collective wisdom of strength, of knowledge, of culture for their healing. One example that I'll give on how policies and procedures can be adapted. One of our team members is a roadman. With that, he travels quite a bit for different events, whether it's different cultural practices that he's leading. It may also be for funerals that he's in charge of, but within our home community, if he's in charge of a funeral, he's taking at least four days off from work for that funeral. What we've incorporated into our policies and procedures is a fifth day for him to be able to recover. When we have those roadmen who are leading those funerals, that is a major undertaking for them. We want to be able to support that and not pull away or have him worry about what's happening at work while he's also trying to do this for his family, for his tribe, for his culture. We want to make sure that that is something that's reflected in our policies and procedures to where we're going to support the culture. There can be challenges with that. I'm not saying that each of these things that we've covered will be super easy to implement. It will take some work. There will be some challenges, but what I've provided are some examples of how we can start to make those adaptations within our clinical settings. Okay, next slide, please. Kelly, I think I'm turning it back over to you. Okay, thank you, Dr. Warrior. Now we're going to have time for discussion. Here are some questions to consider. We're going to go through these together, invite you to provide answers in the chat or raise your hand, and we'll have time to call on a few participants to share. So let's focus on the first question. What opportunities have you used to adapt clinical training and supervision to staff in a culturally responsive way? Like I said, you can put it in the chat or if you'd like to raise your hand and share, that would be great. Sometimes what this can look like when we're talking about clinical training and supervision being done in a culturally responsive way, that can really come down to language and asking how you're incorporating culture in your services. How are you using this in the treatment interventions? That can be part of a culturally responsive approach by just allowing that. The other piece would be, how are you taking care of yourself? What cultural practices are you using as a clinician for your own well-being? I see Richard has his hand up. Hello. Thanks for putting on this training. This is really good. I've been working with Native American communities. It'll be a better part of 10 years this September. One of the things I look at is learning from the clients that I have in terms of asking them what their cultural practices are, because I'm an outsider. I see it as an opportunity to learn and to basically show appreciation and respect for the practices that are being utilized in the community. Another thought on my head, I think I'm having a senior moment. Two, as far as self-care is concerned, falling back on the things I value personally, both within my own spirituality and just in life practices too, that I do make sure that I am taking care of myself away from work as well. Oh, I know what the other thing, a very specific thing that I utilize in relating to my clients is rather than saying, I consider it a privilege to work with my clients, with Native American clients in particular, I say, I let them know that it is an honor to work with them, because I know that word is very important in the Native community. That's not just a saying, I do honestly consider it an honor to work with Native American community. I use that word intentionally. That's my little spiel there. Thank you so much, Richard. I love what you referenced in terms of learning from them as well, because as we discussed, we talked about the collective wisdom that's there, that they come in with their history, they come in with their strengths. That's so important for us to be able to recognize that. Thank you so much for sharing. Is there anyone else that would like to add to this part of the discussion? Okay, let's move on to the next question. Have you encountered any barriers when implementing- Actually, Kelly? Yes. I'm sorry, there's a question in the chat. Oh, okay. From Amy Campbell. Dr. Warrior, do you have suggestions for how a program or clinic might start to think about how to evaluate their training and supervision? Yes, absolutely. So I'm gonna ask if Kelly would be able to share this or whoever coordinates this. I can make sure to send, there is a self-assessment that you're able to do for your clinics in general. So we can send that out and make sure everyone gets a copy of that assessment to look at where are we in terms of cultural integration? Where are we in terms of these power dynamics? All of those things that we've referenced that are also influencing the model that we showed, we can absolutely share that with you and I'll make sure to send that to Kelly today for your clinic to start off with just a self-evaluation. Yes, I can absolutely get that out. Thank you. Thank you. Okay, any other questions with the first or on the first discussion topic? Okay, have you encountered any barriers when implementing native cultural adaptation in your programming and or practice? You can type it in the chat or raise your hand. As a provider and early on in my career, one of the things that I recall a supervisor saying to me or asking me was if the culture was part of my agenda and not necessarily about the relatives. And it really just kind of made me shrink down as a new clinician, as an early career clinician to where I was nervous about incorporating culture because that's what the, remember the power dynamic that we talked about, that was the impact to where it almost seemed like I could not bring culture into the session because that was my agenda. Just giving an example there, but I see Richard has his hand up. Hello again. I would really appreciate your feedback on something that's come up recently. We're a behavioral health, I work for behavioral health department within the overall health clinic of the Washoe tribe. And recently in particular, first of all, our behavioral health department has grown by leaps and bounds, particularly since the pandemic has calmed down. Our director has done a marvelous job of just really expanding the services that we're providing the community. And I have a lot of respect for her. One of the challenges that we're having is that of recent say within the past year, we have had more and more of our own employees seek services from us. And just recently, in fact, in this past week, I had a very direct conversation with one of my colleagues who is seeing one of our employees, I'm seeing one of our employees. And at the same time, we're having department activities going on, such as like right now it's Christmas. So we've got a Christmas luncheon going on today. In January, we're gonna have a day set aside specifically for team building and slash also celebration more expanded. And my colleague basically pointed out that she really felt like we are in a dual relationship, we'll end up in a dual relationship with our clients that is unethical. And I think wanting me to buy into it, I respect it, but I'm not sure I'm totally into it myself because we are a department, we're coworkers with each other, we're in a sense a bit of a family. And to me, it's like where I'm at personally, and this again, where I really would appreciate feedback is I will set clear boundaries as far as engaging in those activities, maybe having some distance with that person during that group activity that we're doing in that type of thing, and then being able to maintain my counseling relationship with this person. I think next week when we have treatment team, I've been encouraged by one of my other colleagues that have also been confronted with this to bring it up as discussion, should we as a department be seeing our own coworkers? Again, these coworkers are members of the tribe. Theoretically, they should have access to the services that we provide, but are we crossing a line here? What's your thoughts on this? Yeah, that's a lot. And we touched on that in terms of the role of dual relationships when we're talking about small communities, rural reservation, or even just in Indian country in general. And I agree with where you are in terms of setting those clear boundaries. And I also think about other partnerships that may be established. Luckily, we have telehealth as an option. And in those situations to where we might see that the relationship is, the clinical relationship is being impacted by this coworking relationship, then we would want to step back. So I would highly recommend ongoing consultation for that, for those particular relationships where we do have roles that are intersecting with other roles within our organization, but our people are still deserving of quality clinical care, no matter where they work, no matter where they live. So we still wanna make sure we're providing that to them, but also having a backup plan in terms of what might be some other options that would be telehealth that the tribal services could potentially cover to make sure that there is no out-of-pocket expense for that individual if they were able to get those for free. So the clear boundaries, the ongoing consultation, the other services that might be available through telehealth as a particular option would be a few things that I would recommend considering as you move forward. So from what I'm hearing from you is that what we are doing isn't necessarily unethical so long as we have those clear boundaries, but then also looking at perhaps collaborating with another tribal health center for those particular services and getting them connected with that so that they can get the services that they are entitled to. And then maybe we are able to have clearer boundaries with that within our own department. Is that, did I hear that correctly? Yes, and what I would also highlight with that though, Richard, is really paying attention to what the policies are for the tribe. If they have something specifically written in regards to dual relationships, you definitely wanna take note of that. And then whatever ethical codes are guiding your work. So compare that from, so for me as a psychologist, I follow the APA code of ethics. Having a dual relationship would not jeopardize my license as long as I have clear documentation and there are clear boundaries. We can engage in dual relationships with, of course, with limitations to that, but that does not jeopardize your license. Again, you have to go back to your particular code of ethics and what the tribe's policies are, and you may wanna review what the state policies are as well. Thank you so much for that insight. Okay, so let's go ahead and look at the last question for time's sake. So what strategies did you use to overcome any of these barriers that you faced? And remember, these questions are open to everyone, so please type them in the chat or speak up if you'd like to share. I see Brett put in the chat cultural humility. Yeah, I guess I could speak to that for just a second. I think that one way that I have tried to overcome some of the barriers and to become more adept at culturally responsible clinical work is just to approach everything as much as what I can from a position of cultural humility to recognize that I do have a lot to learn. I have a lot to share, but I also have a lot to learn. And in that exchange, I think that there's a potential for just massive growth. And I just I think that that's a cornerstone for me to overcome some of the barriers. Thank you for sharing that, Brent. And you're absolutely right. When we look at cultural humility, that's removing those power dynamics. Remember, as we talked about how we're decolonizing what services look like, what training and supervision can look like. Cultural humility is going to remove any of those power dynamics. And so that's a great way to overcome some of those challenges. Thank you for sharing. Yes, thank you. Thank you for your participation. And we're going to move on to this next slide. So now we're going to move into a discussion around technical assistance. And as a reminder, ORN TA support is free and can respond to a range of requests that vary in scope, depth, and length of time. Twyla Millari, who is a TS for the Tribal TOR Southwest and East, will now discuss a TA request example and the process of how it was completed. This will hopefully give you an idea of what we can provide as well as spark ideas on ways we can help you and your program and the great work that you guys are doing. So Twyla, I will pass it off to you. Thank you, Kelly. And thank you, Dr. Warrior. Good morning. Good afternoon. Yá'át'ééh. I'm Twyla Millari. I am Dineh, also an enrolled member of the Navajo Nation from the southwest parts of New Mexico. I will be providing an overview of a TA request. As Dr. Warrior pointed out, there are various clinical adaptations and traditional healing approaches. And this TA request is one of those requests where the TTS was able to provide technical assistance but also incorporate a tribal consultant to provide a training on integrating traditional healing and cultural practices into treatment. We received this TA request from a licensed clinical social worker working at an IHS clinic. This clinic was in a rural setting. It was also providing ambulatory services to approximately 45 to 55 staff members. The request came in because the clinical team was also observing a rise in OUD rates among the patient population, and they were interested in increasing knowledge among their staff and also affiliated providers. They did ask for some guiding principles to incorporate this training. So below, you'll see that they did request a one-hour virtual training. The staff recognized that there would be labor costs for a large majority of their staff to attend the trainings as well as billing considerations. Therefore, they had asked that it also be virtual. I want to also note that this same training was provided in a different tribal community at IHS hospital in a two-part series. So just know that the training format can range from one hour to a two-part series. The clinical team also identified that the audience would be both a mixture of direct providers, physicians, case managers, medical assistants, and also RNs. So with that, they noted that there was some communication gaps and knowledge gaps within the care team across various departments, so they aimed to include as much providers as possible. A third component of the training, they hoped that the staff would accomplish obtaining CEUs, so we did facilitate that as well. And the requester also had asked if they could incorporate their own participant training evaluation. They wanted to evaluate the trainer and also next steps that their team could take. Next slide, please. And this is the TA process from the beginning. So the first step, we received the TA request, the social worker submitted it on the ORN website. The second step is the TTS, myself, met with the requester, and we talked through more specifically what they were seeking out of the training. And third, my role was to identify a tribal consultant that would best fit their requests. And moving forward, we were able to meet with the requester, so after I identified the consultant, we met with the TA requester, I would say about two meetings to better understand what they were seeking, and the tribal consultant walked through the steps to identify specific content areas. After that step, the TA consultant agreed that this would be a good match, and the TA tribal consultant submitted their materials for vetting with our indigenous work group. And the last step, we all met as a team to finalize the training logistics, the delivery, and the content. Next slide, please. The training consultant that was identified was Dr. Daniel Dickerson. He is Associate Research Psychiatrist at UCLA. He is also a principal investigator investigating potential benefits of substance use intervention utilizing drumming for Native Americans. Some of his highlights of his work include DARTNA, which is the Drumming Assisted Recovery Therapy for Native Americans. In addition, Dr. Dickerson specializes in evaluation of substance use characteristics in American Indian and Alaska Native populations, and the role on substance use behaviors and the development of substance abuse treatment for American Indian and Alaska Natives. Next slide, please. So at the implementation stage of delivering the training, the title of the training was Cultural-Based Approaches and Psychosocial Interventions for Stimulate Use in Native Communities. Dr. Dickerson identified three learning objectives. First, he described how American Indian and Alaska Native traditional practices have historically helped to maintain healthy communities. Secondly, he focused on explaining cultural-based approaches in helping American Indian and Alaska Native people with stimulant use disorder. In this second objective, he also highlighted three areas of cultural-based approaches, which he, I would say, expanded on and very much so highlighted, which was the Drum Assisted Recovery Therapy for Native Americans, also community healing circles, and motivational interviewing and culture for treatment. The third objective he explained and went further in depth on understanding the role of healthy and supportive social connections in overcoming stimulant use disorders among American Indian and Alaska Native people. At the end of the training, we also met with the requester and identified outcomes. So what were some tangible outcomes from this training? The requester implemented their survey and evaluation, and a total of 36 participants participated in the virtual training. Out of that 36, 73% reported that the training could enhance patient care overall. So they took some components, and about 73% felt confident that they could incorporate that into patient care. They also identified as a team how they could integrate learned knowledge into practice. There were three areas which the staff reported on, which was the first was to improve interprofessional communication among departments regarding the topic. And eight of the staff members also reported they could enhance team collaboration. And third, the next was clarifying team roles. So they felt that some of the staff had team roles that they could enhance or improve among this content area. Next slide, please. And we are also able to ask questions regarding the TA request and process. I'll also turn it back to Kelly. Thank you. Thank you, Twyla. So this next slide is just to give you an idea of what we can help you with. So we can help provide Native research in regard to opioid use disorder and substance use disorder. We can provide Native resources, consultants, and Native SUD subject matter experts, presentation development, training for staff, community health board members, OUD SUD train-the-trainer, meeting facilitation, marketing materials, ideas for OUD SUD patient outflow, Native-centric MAT services, MAT startup or expansion of services, social media campaigns, conference planning, and then obviously so much more. Okay. So to ask questions or submit a TA request, you can visit the opioidresponsenetwork.org or email at ornatripleap.org. And upcoming webinars and recordings, the next one will be January 30, gosh, I think it's January, sorry, I didn't, I didn't put the date there. It is, the next webinar will be January 25th. January 25th at 12 p.m. mountain time. And this one will be over incentive-based recovery for substance use among American Indian and Alaska Native communities, and I apologize for having that specific date in there. And then all webinar recordings will be available at opioidresponsenetwork.org slash TOR within two weeks. And the ORN evaluation survey link is below. So if you could complete the survey, we would appreciate it. We have about seven minutes left, and I will pause there to see if anyone has any questions. We can go through a few questions real quick before we end for the day. I'm looking through the chat real quick. So I don't see any questions in the chat right now. So we will go ahead and close for the day if you can remember to complete the survey. In closing, I would like to say thank you for the work that you do. Thank you for participating and I hope you all have a happy and fulfilling holiday season. Thank you all have a good day. Thank you.

culturally responsive care

behavioral health

Native American communities

clinical adaptation

resistance to treatment

historical trauma

traditional healing approaches

evidence-based practices

cultural values

cultural protective factors

opioid use disorder

Opioid Response Network