Alaska Natives in Recovery and Indigenous Cultural Generativity: Sharing Redemptive Narratives to Improve Quality of Life

Abstract

This chapter explores motivating and maintenance factors for sobriety among older AN adult participants (age 50+) from across Alaska. Alaska Native Elders are motivated to abstain from, or to quit drinking alcohol through spirituality, family influence, role socialization and others’ role modeling, and a desire to engage in indigenous cultural generative activities with their family and community. A desire to pass on their accumulated wisdom to a younger generation through engagement and sharing of culturally grounded activities and values, or indigenous cultural generativity, is a central unifying motivational and maintenance factor for sobriety. The social work implications of this research indicates that family, role expectations and socialization, desire for community and culture engagement, and spirituality are central features to both Alaska Native Elders’ understanding of sobriety, and more broadly, to their successful aging. Social workers can use motivational interviewing techniques to explore Elders cultural motivations to encourage and support relapse prevention and support older Alaska Native adults’ desire to quit drinking and attain Eldership in their family and community. Sobriety can put older Alaska Native adults on a pathway to successful aging, in positions to serve as role models for their family and community, where they are provided opportunities to engage in meaningful indigenous cultural generative acts; roles they have learned about across their lifetime.

1. Introduction

In recent decades, numerous studies have documented problems associated with drinking alcohol among American Indians and Alaska Native peoples, however, little research has focused on developmental factors and whether or not they would contribute to Alaska Native sobriety and relapse prevention [1, 2, 3, 4, 5, 6]. Some research has focused on the developmental stages and the appropriate treatment methods for each stage, with a primary focus on young adults and identity formation, and this chapter will build upon this work with a focus on alcohol treatment and recovery for older adults. This chapter will discuss the unique characteristics and experiences of Alaska Native people, how Alaska Native Elders achieve Eldership in their family and community and fulfill the role expectations in their family and community, and the role of generative acts and behaviors in their recovery narratives. This chapter will conclude with a discussion of motivational interviewing with older adults and how it can be used to help elders completing treatment to find their motivations through indigenous cultural generative acts and behaviors, which will serve as the foundation of a peer-based relapse prevention program for Alaska Natives and other indigenous populations of all ages.

1.1 Alaska Native peoples

The State of Alaska is two times the size of Texas and is home to over 700,000 people and 15% of those self-identify as Alaska Native [7], which are divided into five major groupings, including the Aleuts, Northern Eskimos (Inupiat), Southern Eskimos (Yup’ik Eskimo), Interior Indians (Athabascan), and Southeast Coastal Indians (Tlingit/Haida/Tsimshian). These groupings are based on cultural and linguistic similarities of people living in various regions of the state [8]. Each of these cultural groups are distinct, consisting of complex kinship networks, developed subsistence hunting and gathering practices and technologies, and unique languages, belief systems, art, music, storytelling, spirituality, and dance traditions to name a few [9]. Roderick details the commonalities among the Alaska Native cultural groups, including their relationship and connection to the environment. They honor both the land and waters upon which their lives depend, have respect for the fish and animals, and value community over individuality, sharing with others, and respecting and learning survival skills from their Elders [9].

According to the 2010 Census, there are 12,318 Athabascans, 7696 Aleuts, 20,941 Inupiat Eskimos, 9996 Tlingit/Haida/Tsimshian, and 27,329 Yup’ik Eskimos living in the State of Alaska (www.census.gov).

The older adult population is growing rapidly in the United States, with high rates in tribal communities. With this growth of the elders in Alaska Native, reservation, and urban communities comes the need for age appropriate treatment programs. Following Erik Erikson’s stages of human development [10], this paper discusses the role of generativity (seventh stage) in the recovery process for AN older adults and how this developmental stage can be integrated into alcohol treatment for Alaska Native and other Alaska Native peoples to enable them to quit drinking and become role models for their families and communities. This chapter attempts to discuss the importance of generativity and redemptive narratives in the role development of “Elders” in tribal communities and argues for the incorporation of this developmental stage into a treatment program to prevent relapse for Alaska Native older adults struggling with alcohol use disorders and improve their quality of life.

Alaska Native community partners have repeatedly advocated for a shift from a problem-based to a strengths-based model of relapse prevention in alcohol treatment. Rather than focusing on problem behaviors and reasons why people drink and cannot recover, this approach highlights individuals and subgroups successful treatment outcomes or who have been protected from active substance use problems [11]. Rather than focusing on failures in alcohol treatment and recovery (e.g., relapse), community partners are highlighting reasons for sobriety and older adults sharing their recovery journey. This shift in focus was spearheaded by tribal leaders and researchers in Alaska in direct response to the Barrow Alcohol Study and the impending damage of this study on the lives of Alaska Natives. Obtaining a better understanding of those who are successful in their recovery contributes to our understanding of the protective factors from alcohol use disorders [3, 4, 12] and guide the development of alcohol intervention approaches built upon strengths found in the redemptive narratives. This need to pass along experiences and stories to serve as examples of recovery is one form of generativity, which Erik Erikson’s seventh stage of human development. In particular, it is important to highlight cultural strengths that exist in native communities; these strengths include values based having a desire to pass on their experiences, wisdom, lessons, and cultural values and beliefs [11], specifically those experiences related to their experiences while drinking, their journey to recovery, and how they use those past experiences to help others on their own journey. We will refer to these as generative acts and behaviors.

2. Definition of AN Elder

A particularly important distinction in the later life role for Alaska Native older adults shared with many other American Indian and indigenous groups is that of Elder. In this paper, the term “Elder” is capitalized to differentiate this. In indigenous communities, community and family members respect their Elders, seek them for their knowledge, skills, and history, and this cultural convention distinguishes those who have practiced subsistence activities (gathering and harvesting traditional foods), engaged in healthy behaviors to maintain physical, mental, and spiritual health, taught others, and served as an integral part of their community as role models and leaders [13]. In this way, the role socialization that occurs across the lifespan that enables a community member to become an Elder in Alaska Native communities is incompatible with problem drinking.

This concept of elder, according to Erikson [14], was formulated in our middle years, a time when we had no intention of imagining ourselves as old. Erikson [14] goes on to state, “One could still think in terms of ‘elders,’ the few wise men and women who quietly lived up to their stage-appropriate assignment and knew how to die with some dignity in cultures where long survival appeared to be a divine gift to and a special obligation for a few” (p. 62). The lifespan of Alaska Native Elders today continues to increase with improvements in health care technology and services, and this longer lifespan may have a direct impact on the recognition and respect of Elders in rural communities [15]. How elders are viewed in society today is vastly different from the past, and our views of the elderly will continue to shift with social and cultural changes. In addition to changes in how society views its elders, family dynamics are shifting.

2.1 Generativity

The psychoanalyst Erik Erikson developed a theory of affective, or emotional, development complementary to the developmental theory of Sigmund Freud, who also studied human development. Erikson identified eight stages of development, and this chapter focuses on the seventh one, adulthood, which includes the concept of generativity, or leading the next generation [14]. During this stage of development, the individual is focused on being a contributing member of society and concerned for the wellbeing of future generations. Lerner [16] explained that during this stage of development an individual successfully plays the role society expects of him (role expectation). More specifically, if they are contributing and producing what is expected, they will experience a sense of generativity. Generativity, broadly defined, refers to not only the creation of children, but also to the production of things and ideas through work. Most of Erikson’s work, however, focused on the generation of children. Notably, Erikson does not require that individuals have their own children to achieve, or experience, the benefits of generativity.

The concept of generativity is important in Alaska Native cultures, which they refer to as caring for the future, or seventh, generation. It is important to note that generativity is a personal resource given to others and is not used to eliminate the elders’ own stress and life events [17], but instead is used to improve the quality of society, such as its role in redemptive narratives and alcohol recovery. Erikson’s understanding of generativity is in direct contrast to how mainstream Americans emphasize our independent achievements to the extent that people become involved in themselves and their successes and neglect the responsibility of caring for others [18].

As stated earlier, generativity, or engaging in generative behaviors and acts, is important in most indigenous cultures, including Alaska Natives, which focuses on caring for the future, or seventh, generation; the youth and future of indigenous communities. For example, we need to remain sober and share our recovery story and serve as role models, not just for our children, but for the seven generations (seventh generation) ahead of us.

Spicer [19] found in his study that American Indian and Alaska Natives understood their role of helping family and community gave them a sense of purpose and replaced drinking with healthier behaviors. Burman [20] found that American Indian and Alaska Native individuals in recovery wished to be role models for others in and out treatment, sharing their experiences drinking and after becoming sober in hopes they will provide an example of life without alcohol, but if they choose to drink, or struggle with alcohol, they know someone they can talk with if they are struggling.

Most older adults, regardless of gender, race, or ethnicity believe generativity is important to achieve a sense of purpose, feeling that one has something valuable to give to society and is able to help others. Keyes and Ryff [17] explained that these feelings support and encourage social engagement of older adults as well as enabling them to contribute to the wellbeing of their family and community, leading to continued engagement in meaningful activities and events, contributing to the Elders’ sense of purpose and generative development [5, 21, 22, 23]. Spicer’s [19] study explored recovery as a cultural process involving restoration of the cultural self, concluding that drinking is incompatible with a proper way of life for American Indian and Alaska Native people, and that through abstaining, people in recovery were able to restore themselves to this proper American Indian and Alaska Native way of life and serve as role models for others, and “live life as it was meant to be” ([24], p. 209). Another aspect of this development is the redemptive narrative; taking past negative experiences, reflecting on them and finding purpose and meaning in those negative experiences, and highlighting the lessons learned and positive outcomes of a negative event, such as receiving a DUI or being jailed for public intoxication to educate others and help them to avoid similar challenges on their own journey or develop their redemptive narrative.

Generativity, in Erikson’s terms, encompasses aspects of human development that echoes various indigenous cultural values and beliefs, including teaching the future generations and passing on their skills and knowledge to preserve their legacy. This understanding of generativity is limited in scope and does not possess the cultural values and practices Alaska Native Elders consider important for aging well, including recovery from alcohol. To weave these indigenous cultural values into Erikson’s understanding of generativity, my colleague and I defined indigenous cultural generativity as “any act of an older adult where they pass on traditional values, subsistence practices, language, beliefs, and any other activity that preserves and passes on the culture of the family and community” ([25], p. 218). What makes indigenous cultural generativity unique is that Elders engage in generative behaviors and acts to preserve the history, language, and cultural values and beliefs of an entire, family, community, culture, and way of being for seven generations and not solely to preserve the legacy of one individual Elder. More specifically, Alaska Native Elders are generative, and encourage their family and community to be generative, to ensure their native way of life, indigenous ways of knowing and being, the land and subsistence practices, and their family and community are healthy and seven generations from today possess the skills and knowledge to grow old and become healthy Elders.

A segment of the Alaska Native population struggle with alcohol use disorders across the lifespan, starting when they are younger, and as they grow older, their continued struggle with alcohol prevents them from enjoying their later years, prohibiting them from aging successfully, and filling the role expectations of Elders, including culturally generative acts. These acts include teaching arts and crafts, native language, and subsistence gathering and harvesting, and on a deeper level, the underlying values and worldview of their culture, as well as sharing their positive and negative experiences with alcohol and recovery. Such findings regarding what Alaska Native Elders consider having worked for them can influence future recovery programs in understanding what motivated them to quit problem drinking and what protects their sobriety. This knowledge can guide development of culture-specific alcohol treatment approaches, and more broadly, alcohol prevention strategies using redemptive narratives and generative acts and behaviors.

3. Community engagement and successful aging

The Alaska Native community serves an important role in the Elders’ lives. Community engagement provides the Elders with a sense of purpose and a role in the community [26]. The quality of life for elders is directly related to the quality of their social network [27], which is an important aspect of the lives of the Alaska Native Elders. The roles Elders hold in their community also contribute to their sense of generativity; almost every Elder discusses the importance of having opportunities to pass down their knowledge to others. Alaska Native communities and families value their Elders and understand the importance of their wisdom and experience, providing opportunities for them to participate and educate those who were interested [17]. The ability to forge connections with others (i.e., family, community) is a result of hope and optimism, healing, and empowerment [13]. To connect with others is to find roles to play with others, such as serving as a sponsor or role model of others in recovery [25]. These relationships can be strengthened by discussing common experiences, such as drinking or experiencing other mental illnesses. Being provided opportunities to serve as a role model for others with the same diagnosis brings people together and allows them to be empathic listeners.

3.1 Generative concern

The motivation to be generative emanates from inner desires and cultural demand and is reflected in the person’s level of generative concern [28]. Generative concern predicted life satisfaction, but generative behavior did not [28]. Elders’ generative concern stems from their desire to educate and guide the next generation [10] to ensure they live healthy and productive lives that are meaningful. Alaska Native Elders share concerns of the youth with the introduction of technology (e.g., television, internet, cellphones), and how their identity is split in two worlds (Indigenous and Western) and this leads to lack of engagement and sense of identity and purpose. Generative concern, or concern for the future generations (seventh generation), stems from a generative commitment, which is enhanced by their generative concern.

Research has consistently demonstrated that self-reported generative concern shares a significant, positive relationship with measures of life satisfaction, self-esteem, happiness, and a sense of coherence [29, 30, 31, 32]. In addition to generative behaviors and actions, individuals also develop their redemptive narrative, which they share with others, such as those struggling with alcohol use disorders. Generativity, in the context of alcohol use and misuse, relates to transforming negative events in life into something more positive. Individuals make use of generativity to redeem themselves as part of their generative efforts, as well as pass on these lessons and experiences to others. In the alcohol and prisoner literature, these redemptive narratives also involve ex-substance misusers to act as supporters or mentors to help current users with their substance misuse problems as one means of recompense.

4. Motivational interviewing

Some researchers have applied Erikson’s ideas around stages of human development and indicate that alcohol prevention is best implemented during adolescence to help them resolve role confusion and achieve a positive identity [33]. Researchers also note that prevention programming needs to be developmentally appropriate and target behavioral irregularities at specific developmental stages that might be indicative of future substance abuse [33]. Many of the older adults in tribal communities have undergone shifts in identity and battle with addiction and other mental health conditions, preventing them from fulfilling their role of “Elder.” A majority of the Elders have a strong desire to teach their grandchildren, as well as others in their community, and addiction has been a barrier. Tapping into this generative desire of Alaska Native Elders, working with them to explore their motivations to quit drinking and the maintenance factors, we can develop motivations for recovery and support these Elders to fulfill this stage of development and enable them to become role models, teachers, leaders, and grandparents; all of these roles are incompatible with alcohol misuse.

Motivational interviewing (MI) is a style of behavior change counseling developed originally to prepare people to change substance use behaviors [34, 35], by facilitating exploration and resolution of ambivalence [36]. Miller [35] conceptualized motivations as a state of readiness for change, rather than a personality trait. MI is a method defined by Rollnick and Miller [37] as a directive, client-centered style of counseling that helps clients to explore and resolve ambivalence about changing their drinking behaviors. As a state, motivation may fluctuate over time or from one situation to another, and can be influenced to change in a particular direction [35, 38]. While using client-centered techniques to build trust and reduce resistance, the provider focuses on increasing readiness for change [39].

Rollnick and Miller [37] distinguish between the MI principles and the “spirit” of MI, which is important, which means being with the clients. Within the spirit of MI, readiness to change is not seen as a client trait, but a “fluctuating product of interpersonal interaction ([37], p. 327), and motivation to change is viewed as something which is evoked in the client, rather than imposed [38]. Using an empathic style, it is the therapist’s task to create and amplify any discrepancy between the client’s present behavior and important goals, resulting in cognitive dissonance [38, 40, 41]. Listening reflectively and eliciting motivational statements from clients, examining both sides of client’s ambivalence and reducing resistance by monitoring clients’ readiness and not pushing for change prematurely is one the primary principles of MI [34].

MI aims to support self-efficacy by seeing the client as a valuable resource for finding solutions to problems. However, while the client is seen as responsible for choosing and carrying out personal change, MI also acknowledges that, at the same time, the client must have a belief in their ability to change [38]. Miller and Rollnick [42], recommend the MI therapist focus on increasing the client’s belief in their ability to change, although they do not give suggestions about how this can be achieved apart from acknowledging successful behavior change in the past [38]. MI aims to alter how a client sees, feels about, and means to respond to the problematic behavior. The ambivalence is resolved by focusing on the client’s wants, expectations, beliefs, fears, and hopes, with particular emphasis on the inconsistencies between these and the problematic behavior [38].

4.1 Alaska Native older adults and motivational interviewing

Although a substantial body of literature exists affirming the efficacy of motivational interviewing to behavior change, very little research focuses on its use with older adults [43]. Only one study was identified that examined the effect of MI on alcohol consumption among older adults. Gordon et al. [44] examined the effect of brief interventions on hazardous drinking behavior among older adults aged 65 and older. Numerous studies have demonstrated that MI has been used successfully with other populations and it appears the non-authoritarian approach and emphasis on personal choice is likely to be acceptable with Alaska Natives who seek self-determination and self-empowerment [38]. Longshore et al. [45], for example, have included MI in a culturally congruent intervention for African Americans, stating that MI’s emphasis on personal choice, and avoidance of advice giving and confrontation as reasons for their view.

Although limited in number, MI studies conducted with older adults highlight the potential of this approach for achieving important behavioral changes in older clients. Given the serious negative effects of problematic drinking on the health and wellbeing of older adults, such evidence should be considered and tested with Alaska Native Elders. These studies suggest that MI techniques are both acceptable to older adults and are capable of producing change in a variety of health behaviors in a relatively brief period of time [43]. One of the significant features of MI is the brief time period within with documented changes have occurred in clients’ lives.

Motivational interviewing (MI) [35] is an appropriate treatment method to be used with Alaska Native Elders because of its ability to shift focus from exploring the intrinsic motivating factors to quit drinking and remain sober to the extrinsic motivating factors, including grandchildren, family, and community responsibilities expected of Elders. Using MI with Alaska Native Elders who recently completed treatment, social workers can help them explore their motivations for recovery; what do they miss about being engaged with family and community, what are their cultural motivations to be sober, and what did alcohol take away? People grow up with thoughts and ideas of what their life will be like as an Elder and struggling with alcohol use disorders, being removed from activities and people that contribute to their cultural sense of identity, and alcohol destroys their ability to become an Elder. Elders were raised in strong family and community networks, where everyone supported each other in good and bad times. Building on this strong cultural value of community engagement and support, these sessions can also include partnering with other Elders in long-term recovery as a peer-recovery coach [46], who can share their motivations for recovery and work alongside the social worker to develop a list of motivations and reasons for sobriety that will replace their drinking behaviors or temptations to relapse.

Generative behaviors and actions can serve as factors that would contribute to an alcohol treatment program and assist Alaska Native Elders to explore their individual motivations and replace their drinking behaviors with acts of teaching and leading others, passing on their narratives, and helping others on their journey of recovery [25]. Many Alaska Native people share their story of recovery to assist others from having similar experiences. Sharing their stories also empowers them to continue on their own journey of recovery, as well as instill hope and optimism for the storyteller and the listener [47]. Through the telling of their story, they are able to continue to revise their story as they learn more about their own experiences, continually revising their story to emphasize a strengths-based perspective of recovery (Figure 1).

Figure 1.

Indigenous cultural generativity model of recovery.

5. Conclusion

This chapter proposes that generative acts and redemptive narratives can serve as a potential relapse prevention for Alaska Natives Elders, and other ages, who recently completed alcohol treatment. The increasing awareness of alcohol problems in tribal communities and this shift from negative to positive outlooks on sobriety and quitting drinking highlights the strengths and resiliency factors that exists within Alaska Native and other indigenous communities. The topics discussed in this chapter lay the groundwork for longer-term research objectives, focusing on developing and implementing a supportive alcohol relapse prevention program promoting healthy aging for Alaska Native older adults and builds on the strengths of their cultural values and beliefs, which align with generative acts and behaviors.

Alcohol abstinence rates are higher for Alaska Natives than other racial and ethnic minority groups, pointing to important sources of resilience [48, 49]. There is a need for continued work in the development of alcohol treatment and relapse prevention programs to address the unique context of Alaska Native people and communities, specifically alcohol treatment for racial and ethnic minority older adults. There is also a need for increased attention to strengths-based and community-oriented approaches to substance abuse research [11] and program development. This chapter addresses this need and contributes to the shift to focusing on the strengths and resiliency of those Alaska Native who have quit or abstained from drinking to serve as role models for other Alaska Natives Elders, and other ages, still struggling with alcohol. This chapter provides the reader with a better understanding of what it means to live a better life and established the pathway to age successfully, live the good life [50], or live “life as it was meant to be lived” ([24], p. 209). Spicer [19] states that we are “forced to revise our understandings not only of what it means to change drinking behavior, but, indeed, of what it means to be restored to wholeness” (p. 238). The findings of this study will also move Alaska Native communities forward by highlighting the successes and stories of the Alaska Native Elders who are aging well and have a lifetime of stories, experiences, and motivations to share with others.

This heightened consciousness and spirit of self-determination and improving one’s health and wellbeing is a positive force for our sobriety movements and rebuilding healthy families and communities. Treatment and continuing care needs to focus more directly on strengthening the protective resources that promote abstinence and recovery [5]. For example, information about the status of protective resources that promote remission and recovery can help identify individuals who have a high risk for relapse and target them for more intensive interventions. Being engaged in meaningful and worthwhile activities (family, community, cultural) are important for Elders and programs and services should assist Elders in determining the activities that promote a sense of purpose and worth through Motivational Interviewing and self-assessments.

5.1 Implications for social work education

This chapter is the first attempt to apply Erikson’s seventh stage of development to Alaska Native Elders’ recovery. This chapter provides the reader with a better understanding of what it means for Alaska Native Elders to quit drinking and establish the pathway to age successfully in order to live the good life [50] and how they achieved and maintained sobriety and wish to help other do the same in their lives. Studies on older adults with alcohol use disorders have found that providing age segregated treatment, avoiding confrontational approaches, and involving family and friends in treatment have been effective in promoting long term recovery and relapse prevention. Treatment and care for Alaska Natives with alcohol use disorders presents several unique challenges. First, the near annihilation, forced assimilation, and lifelong discrimination are influential factors in the higher prevalence of alcohol use disorders among Alaska Native Elders. Unresolved trauma-related symptoms can contribute to the abuse of drugs in an attempt to cope with the effects of trauma among all ages. To shift the focus from alcohol related problems to resiliency factors and reasons for sobriety, this chapter identified protective factors, or reasons, for sobriety and recovery among Alaska Native Elders, which included individual, family, and community factors, all of which may protect individuals from alcohol misuse. One of the key aspects of Alaska Native Elders becoming sober and abstaining for substances, including alcohol and drugs, are their desire to give back to their families and communities (coined the term “generativity” by Erik Erikson) and this knowledge can be used as the foundation and principles of an alcohol treatment program for older adults.

One social work approach that may prove successful in working with older adults struggling with alcohol is motivational interviewing. The idea of generativity is grounded in Elders’ being involved in their families and teaching their grandchildren. As social workers it is important to ensure there are avenues in which Elders can be active in sharing their knowledge and experiences with alcohol and recovery with others to enable them to continue experiencing generativity and maintain their sobriety.

Engaging in generative behaviors and acts provides the participants a role and sense of purpose and activities (e.g., subsistence activities, hunting, fishing, arts and crafts) that replace drinking behaviors. Reconnecting with family and community, participating in culturally-grounded meaningful activities are motivations for quitting drinking and maintaining sobriety [17]. Maintaining sobriety is also motivated by their desire to care for family and community members, be role models for others who are struggling, and pass on their wisdom and experiences to the younger generations. Social workers can employ motivational interviewing techniques when working with the Elder to explore their own cultural motivations (e.g., spend time with grandchildren, teach native language, skills, practices) that are characteristic of those who have achieved “Eldership” or become an “Elder” in their respective community and family. This approach encourages the elder to explore how recovery has a positive impact on others in their family and community and enables them to fill a role of Elder that they have thought about in life and had a goal in life, but alcohol may have taken that opportunity from them because of behaviors and actions as a result of alcohol use. Having an understanding of motivations and practices that are common for Alaska Native Elders will help social workers have examples to use to encourage Elders to explore their own cultural motivations that will assist with relapse prevention.

Further work is needed regarding this initial discussion, which can potentially guide treatment approaches focused more directly on strengthening protective resources promoting Alaska Native recovery [5], but also with other indigenous populations. The current results suggest being engaged in meaningful and worthwhile activities with family, community, and culture are important for Alaska Native Elders and can serve as protective factors against alcohol use disorders and relapse and our treatment programs should be encouraged to integrate more strengths and motivations for recovery for each person.