Healing in Hawaii – The Role of Culture in Addiction Recovery
From the moment you step into the Ho’omau Ke Ola Native Hawaiian substance abuse treatment program, you can see that it is quite different from western programs – and quite special.
Those arriving to the program are greeted with a warm “Aloha.” The Haumana (students) in this program walk before you and put their forehead to yours, looking directly into your eyes for a moment – followed by an embrace. This is the Native Hawaiian way, and culture is the cornerstone of their program.
The Ho’omau Ke Ola program is partly funded by SAMHSA’s Substance Abuse Prevention and Treatment Block Grant and is located in Wai’anae – the leeward side of Oahu Island in Hawaii where tourism is low, but substance abuse and domestic violence are prevalent. Poverty, homelessness, and drug addiction have become part of the narrative in this community, but so have family, hope, healing, and recovery.
The students in the recovery program – a multicultural group of young adults – are guided by “Auntie” (Patti Isaacs, Ph.D., executive director of the program) and “Uncle” (Helemano Lee). The very structure of this program embraces the Native Hawaiian respect for Ohana (family) – and in that connectedness comes understanding, growth, and support.
Like western treatment programs, Ho’omau Ke Ola uses cognitive behavioral therapy and a 12-step program, but they are nuanced to be culturally sensitive. For instance, in Hawaii there is a belief that you are your name, so in a 12-step meeting they don’t say “Hi, I’m James and I’m an alcoholic,” but rather “I’m proud to be James and I’m a fisherman.” This is based on a view that the addiction does not define who they are. They do not take an illness-based approach to recovery.
Beside the 12-steps poster in the meeting room hangs a picture of a canoe – another example of balance between Native Hawaiian and western approaches to healing. The “philosophy of canoe” is one that “Uncle” shares with all of the students when they start the program.
All students know that they build momentum forward when they work together. That happens most easily when everyone “rows” together. And when someone falls off of the canoe, they all work to pull the person back in. The symbolism is real for individuals in recovery – that people who feel the strength and compassion of others who help them, get back on track and stay healthy.
The balance between western best practices and cultural curriculum illustrates the comprehensiveness of this program.
Dr. Isaac’s Office in the ‘Aina
A unique aspect of the program is that students also go out to the ʹĀina, sacred and historical land that the program acquired some years ago. The Hawaiian belief is that there is a natural order of connectivity among their ancestors, the earth, and people. Out in the ʹĀina they can call upon their ancestors, talk with each other, and take care of the earth. They grow the taro plant and make poi, a traditional native dish, from the root. They learn the Hawaiian language, chants, traditions, beliefs – and they learn about each other. Dr. Isaacs also has an “office” in the ʹĀina which consists of a few donated chairs and bamboo curtains that work as privacy screens. It’s a space where she can speak one-on-one with people in the program.
The added cultural curriculum doesn’t resemble a western recovery treatment plan, but it works. While students learn and practice recovery strategies, they learn more about themselves, connect with a larger community, and establish beliefs that make them a part of a bigger historical picture. Success is evidenced in the students who graduate and remain in recovery and connected to the community.
Funding Challenges
According to Wendy Nihoa of the Treatment and Recovery Branch of the Alcohol and Drug Abuse Division (ADAD) at the Hawaii Department of Health, about 40 percent of the people on disability in Hawaii are of Native Hawaiian descent. A minimum of 21.3 percent of block grant funds must be allocated to substance abuse programs that serve Native Hawaiians, which are also open to non-Native Hawaiians. The ADAD actually allocates almost twice that (about 40 percent) toward contracted services for Native Hawaiians. A continuing goal is to increase the rates of successful 3rdparty billing for culturally based services in order to increase capacity and the scope of resources in this area.
Although there may be some latitude for how programs are defined, the DSM-5 and insurance coverage are circumscribed.
“While evidence-based practices give us numbers and evidence of success, practice-based evidence also has to be considered and supported,” said Jon Perez, Ph.D., SAMHSA’s Administrator in Region 9, which includes the Hawaiian Islands. “Healing practices that are multi-generational and culturally valued build community health. And the more we integrate a person’s culture into treatment, the more effective that treatment will be.”
The community-based and multi-generational support built into Native Hawaiian programs means they can do a lot with a little – but with substance abuse so prevalent, more is needed.
Healing Happens in Relationships
Along with higher rates of substance use and mental disorders, incarceration and chronic physical diseases also affect more Native Hawaiians than other ethnic groups on the islands. The general belief for treatment is that if the focus is just on the mind and brain – and if the spirit, community, and culture aren’t included – providers will miss an important part of the makeup of a person, and it is much more difficult to establish and maintain wellness.
“We believe culturally-based treatment programs work because they build connectedness, not interdependence,” said Lisa Cook who is the executive director of Kū Aloha Ola Mau, another SAMHSA-supported culturally-based treatment program in Hawaii. Ms. Cook’s program involves many Kupuna (elders). “There is great respect for the elders who serve as role models and teachers. They validate the younger program participants and that builds self-esteem and self-worth.”
Hawaiian programs are open, inviting, and welcoming, because that is the nature of the culture – and this is why it works with people who are from other cultures as well. “When people become involved in Native Hawaiian treatment programs like this, it’s much more intimate,” said Jon Perez. “The art and culture doesn’t just represent feelings, thoughts, and realities the way we in the west would see it. When they talk about their art, they are really talking about themselves. It’s not separate, but integral to who the person is.”
The Ho’omau Ke Ola program also focuses on connecting students in their program with the community. As they learn the chants, songs, language, and ceremonial traditions of Native Hawaiians, opportunities arise for them to perform for tourists, which builds pride in their culture and boosts esteem. The Hyatt Waikiki has not only invited the students to perform for guests, but has also committed to hiring some of the program participants. This is especially important for those who have a difficult time finding and maintaining employment, which can affect housing, stability, health, and recovery.
“It is a given that many will find cultural aspects of a program healing, supportive, and meaningful – and that there is inherent value in these approaches,” said Edward Mersereau, Chief of the Alcohol and Drug Abuse Division of the Hawaii Department of Health. “The challenge and the opportunity are to find ways to ensure that cultural services are afforded the same recognition and validity as “western” services and interventions. What is needed is a harmonious and effective combination of approaches and interventions that provide a continuum of care that effectively meets diverse needs and resonates with people across the spectrum.”
There is recognition – not just in Hawaii – that culturally-based programs work with various ethnic groups because of the connection and interest they build with community. And in Wai’anae, the treatment program is creating a new generation of healthy Hawaiians who heal their past, build their future, and are supported by a program that is family.
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