Taking Action Summit: Trickster Tails: Cultural Considerations in SUD Care

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Good morning and welcome to all of our participants here at Eastman School of Music, as well as those of you who are joining us online. My name is Esther Arnold, and I am the senior technical writer with UR Medicine Recovery Center of Excellence. It's my great pleasure to introduce Dr. Danica Brown.

A citizen of the Choctaw Nation of Oklahoma, Dr. Brown is Behavioral Health Program's director at the Northwest Portland Area Indian Health Board. She has worked as a mental health and substance use counselor, social worker, and youth advocate for over 25 years with additional experience in prevention, drug, and alcohol, and mental health treatment, community and restorative justice, and sexual health with Native American and adjudicated youth. Dr.

Brown specializes in culturally and socioeconomically diverse populations and tribal communities. Her research focuses on indigenous ways of knowing and decolonizing methodologies to address historical trauma and health disparities in tribal communities. Dr. Brown's presentation today is titled Trickster Tales, Cultural Considerations and SUD Care.

We will have a Q&A period after the presentation, and both those of you here in the room with us and those of you online will be able to participate. For those of you online, please use the chat function, and make sure that you send your questions to the co-host rather than the host. Thank you very much for joining us, and I'll turn it over to Dr. Brown.

- Good morning, everyone. (Danica speaking foreign language) I'm Danica, and I'm a citizen of the Choctaw Nation of Oklahoma, and I was born and raised in Northern New Mexico. I currently live in Portland, Oregon, or I live in a little community outside of Portland, Oregon called Scappoose, Oregon. And I work at the Northwest Portland Area Indian Health Board as the behavioral health project's director.

And I'll talk a little bit more about all of that in a few minutes. But Megan is going to share my slides. Or someone was going to share my slides. Megan, is someone going to share my slides?

There we go. (Danica laughs) But I wanted to talk to you today about some of the work that I do in tribal communities and the way that we're trying to conceptualize and address substance misuse within our tribal communities. And so a lot of the work that I do at the Northwest Portland Area Indian Health Board is to, what we would say, incorporate traditional indigenous knowledge into the work that we do. And so I'll just continue with my presentation, and I'll get caught up with my slides when they can get those up.

But, so I work at the Northwest Portland Area Indian Health Board, and what we are is we work with the 43 federally recognized tribes in the Pacific Northwest, including Oregon, Washington, and Idaho. And we serve a number of different purposes. We act as the tribal epicenter for our region. We also have the institutional review board for our region.

And then we have a policy team. We have three tribal attorneys that act as health policy advisors for local, state, and federal advocacy efforts in our community, specifically addressing community and public health. Out of that work, about five years ago. So we are a board.

We have a delegate from each of the tribes that act on our board, and every year they prioritize issues that are impacting our tribal communities. And then as the staff at the board, we are kind of asked to figure it out. So I was brought on to the board four years ago after we had received a great deal of funding to address the tribal opioid epidemic. And what we did was we conducted a needs assessment and survey within our tribal communities.

We talked to public leaders, tribal leaders, tribal health department leaders, but we also interviewed native people who used drugs. And we wanted to get that lived experience and to talk to them about the impacts and barriers to receiving care and change. And out of that we created the Tribal Opioid Response Agenda, and you can find that agenda on our website, which is NPAIHB.org. And you can find all of our tribal opioid response projects on that.

But we created the agenda, and out of the agenda there were seven action items that came out of that agenda. And a number of those actually were talked about in the previous presentation around incorporating harm reduction, incorporating peer recovery and lived experience, providing direct care, housing accommodations, job accommodations, developing a robust workforce. All of those things were identified in our Tribal Opioid Response. Next slide.

But one of the main things that came out of it was that, for us as tribal people, what they wanted to see was more culture included in the work that we were doing and incorporating traditional indigenous knowledge into that work. And that's why they hired me at the board. I had done my dissertation work with my tribal community, incorporating traditional indigenous knowledge into a health promotion initiative with the Choctaw Nation of Oklahoma. And out of that, what we did was we created an intervention that reclaimed our traditional knowledge and values, especially women as the givers and keepers of life.

And then we rewalked the Trail of Tears with Choctaw women. And I interviewed women who've completed that Trail of Tears walk and talked to them about what they learned, what they gleaned from that, and how the long term effects of that were, and how specifically how culture acted as medicine in our tribal communities. And so one of the things that we do is really try to incorporate traditional indigenous knowledge into all of the work that we're doing right now, and that has been specifically mandated by our board members. Next slide.

And so one of the things that I did in thinking about this and conceptualizing, especially the opioid response, was kind of reclaiming one of our trickster stories. And so, in this presentation, what I wanna do is try to help us to understand why tribal people respond and act to service providers the way that they do. And for tribal people in North America, current and past political and social events help shape the context of our lives in ways that many other Americans do not experience. And the study of trauma, historical and present, which is connected to historical genocide, assimilation, oppression, and disparate treatment is connected to symptoms such as depression, suicidal ideation, anger, anxiety, low self-esteem, and other health disparities including diabetes, cardiovascular disease, and it impacts substance misuse.

And so a culturally responsive mental health system must recognize the broader social and political factors that underlie mental health issues for black, indigenous, and other communities of color. For example, data shows that therapy cannot be successful unless it recognizes the range of social and political issues that contribute to client distress instead of only identifying the individual issues that results from the attempts to adjust to the social and political conditions. So what what this is, what I'm saying here is that many times we put the onus of healing and treatment on individuals when it's a societal issue that impacts our experiences, especially as black and indigenous people.

Even the American Psychological Association guidelines recognize the importance of sociopolitical factors in client treatment such as generational history, the history of migration, citizen status, English fluency, and the level of stress resulting from a acculturation and institutional racism. A successful mental health system must find ways to integrate mainstream services with culturally traditional services to address the mental health needs of communities of color within the broader context of their lives. Next slide. So what we've done is we've created a trickster story, and you can also find our trickster stories on our website.

But what we do know is that substance use can impact anyone because it's a chronic health condition and not a moral failing. As a community, we can look towards the trickster or the tricky one to learn how substance use disorders impact tribal communities in similarly sneaky and cunning ways. In oral tradition, in tribal oral tradition, tricksters are a sacred being that assume many forms. It can be old man coyote.

In the northwest, it's the raven. Within my tribe, it's the raccoon. But in general, or more generically, it could be the tricky one. Just to mention a few of its manifestations, but in most of our tribal nations across the country, there is a form of a trickster that is an important part of our creation stories.

But generally speaking, the trickster scandalizes, it disgusts, it amuses, it disrupts, it chastises, and is humiliated by or humiliates. Yet he is also a creative form of transforming their world, sometimes in bizarre or outrageous ways with its instinctive energies and cunning. Eternally scavenging for food, he represents the most basic instincts of the human condition. But in other narratives, he's also the father of tribal people and a strong conductor of spiritual forces in the form of sacred dreams.

In respect to substance use disorder, the substances we use are first medicines meant to cure and heal. And at some point this transforms into misuse or dependency of the medicine, which then can result into chronic dependency. And so when you think about the energy of like people who are misusing or dependent on opioids, it's a very similar energy, right? It's this very primal energy to scavenge, to consume, to steal, to lie, to cheat, which is all against what our innate responses to humanity are.

But we can imagine that there's a trickster spirit in the culprit of this, a spirit that is attempting to teach us important lessons. So the trickster in many of our tribes, he is a teacher who teaches us about humility, about compassion, of living in balance with the natural world, respect for the spirit and the medicines that they use, and respect for the medicine people. So in the use of the word medicine in this context, it's not the western context of like a prescribed or illicit drug, but rather the energy of traditional, that traditional medicines carry. So when we talk about traditional medicines, it can be anything.

It can be water, food, as well as like prescriptions or illicit drugs. That they carry a spirit, and we have to develop a relationship with the spirit of those medicines. One of my elders says is that we need to go into treaty with that spirit of the medicine. And so that's kind of the way that we're shifting the way that we understand and talk about it.

So there are multiple aspects to consider when looking at opioid use in particular. First, the essence of opioids and their medicines is a powerful spirit or prescription to be used. Second, the current perception of SUD stigmatizes and produces shame or guilt. And we wanna break that cycle of shame that happens with people who are using drugs.

And in order to heal and learn the lessons that the trickster has to offer, we need to address our relationships to medicines rather than the SUD process by shifting our understanding and relationship with that medicine, with that spirit, and also with our medicine providers. Next slide. And so what research is starting to show is that chronic substance misuse is pretty intimately tied to our experiences with early childhood trauma. And for me, I just wanna acknowledge that even the word trauma is a term that comes from a Western medical context.

And so what we wanna do is shift also our understanding of trauma. Within a Western context, trauma is really kind of viewed or perceived as some kind of wound, or trauma, or condition that we carry, people who are labeled as PTSD, or complex trauma are perceived as people who carry a lot of wounds and who are, need a lot of like care, kind of psychiatric care. But for us in tribal communities, what we wanna understand and also shift is that trauma is not a burden that we carry. It is something that, it's a survival mechanism that's helped us survive over 525 years of colonial rule.

And so what we try to do is understand it from an indigenous perspective. And so alternative terms centered in an indigenous worldview would be kind of like looking at words like parallel realities, multiple realities, living in a different world or a different time and place. Which recognized the value and legitimacy of these experience, but also the onus is again put on the systems of oppression that have happened versus the individual. So developing an indigenous or decolonial understanding of trauma helps eliminate, again, the stigma that is tied to Western understanding and helps us create space for growth and healing.

Next slide. And so, what we do know about trauma is that it's stored in our bodies, and there's an embodiment of trauma that is created. And it helps us to, it's designed to help us remember danger. So it's literally designed, our body is literally designed to survive.

And that's a beautiful thing. And in early childhood where we develop these fight, flight, freeze, or fawn modes of addressing and surviving trauma, and at a certain point in life, those ways that we have adapted to surviving have become maladaptive, or they're not really working for us anymore. So really the purpose of treatment would be to create and develop better coping mechanisms for survival and trauma. But what we do know is that trauma happens, and it happens in the body, and it happens in the brain.

Next slide. And for tribal people as well as other communities, historical trauma is a factor that impacts us in this current day. Historical trauma results from the long term effects of the oppressive traumatizing policies, attitudes, and beliefs of the colonizers towards American Indian people, the lack of resources and opportunities for American Indian people, and current treatment of American Indian people in this country. Maria Brave Heart Yellow Horse defines historical trauma as, quote, a cumulative, emotional, and psychological wounding over the lifespan and across generations emanating from massive group trauma, end quote.

And Eduardo Duran, and this is my favorite definition of historical trauma. It comes from Eduardo Duran. And he refers to this as soul wounding. These soul wounding symptoms of historical loss are interconnected.

Historical trauma can often produce complex and profound individual and collective biopsychosocial, and cultural, spiritual responses that are related to significant health disparities, including suicidal ideation, substance misuse, and other health risk factors. The negative impact of broad social factors that have influenced, have been influenced by colonization such as racism, acculturation, poverty, are translated into everyday physical and emotional distress experienced by American Indian people. This trauma is now being shown to be epigenetically transferred from one generation to the next.

Next slide. And so this is a picture of my grandfather. His name was Watches Standing Buffalo. And he used to tell me that the memories of our ancestors are passed down on our blood.

And really what he was talking about, what I'm now starting to understand is that he was talking about the epigenetic transfer of trauma. And that trauma can be passed down to offspring due to epigenetic changes in the DNA. Most specifically, it doesn't change the DNA itself, it changes the proteins that surround the DNA, which then get passed down from generation to generations. So in recent years, researchers have learned that trauma can be inherited, but what we're starting to understand too is that our ancestral knowledge and wisdom is also epigenetically transferred.

And so even though there's this change in our DNA, there's also changes in the way that we can understand and relate to our ancestors. Next slide. And so particularly powerful is the process by which colonization has become internalized among American Indian people and serves to shape health outcomes. Genocide against indigenous people in the Americas is one of the most massive and longest lasting campaigns in human history and is continuing to this day.

Historical traumatic events have contributed to these health disparities related to social and behavioral factors such as resulting in increased younger female headed households, significantly higher poverty rates, larger families, lower median income, lower education, et cetera, including health substance misuse. There's a significant body of robust research that shows and demonstrates the harmful impact of colonization on indigenous cultures in the Americas and its contributed impact on indigenous peoples across the planet manifesting through cultural and historical trauma, which is shown to have direct relationship to internalized and lateral oppression seen in American Indian communities that impacts the quality of life for indigenous people and health outcomes in this generation.

These scholars have theorized that there's a connection between historically anchored traumatic events and current health inequalities among American Indians. This connection is relational as highlighted by indigenous people's relationship with the land, each other, and spirit. And so what they're also talking about, as seen in this graphic, is that culture can act as a buffer. Our connection to our identity, to our culture, our inculturation practices, spiritual coping, and traditional health practices can mitigate the impact of historical and intergenerational trauma on tribal people.

Next slide. So what we know is that trauma is real. Trauma is stored in the limbic system of the brain, which is that really old part of our brain, which is not connected to language. And memory is stored in the cerebral cortex of the brain with language.

And so what happens when we're having a traumatic response is that the two parts of our brains disconnect, and all of the blood goes to our primitive part of the brain, which is to set up to survive. And part of trauma treatment is to bring the limbic system back into health with communicating with the cerebral cortex. And the way that we do this is actually very simple. We need to bring oxygen back up to our brain.

We need to regulate our parasympathetic nervous system. And we do this quite frankly, through breathing, through breath, through box breathing, through ritual, ceremony, prayer, meditation, whatever you would like to call it. Next slide. So substance, the bottom line is that substance dependency always originates in pain, whether it's a result of historical or intergenerational trauma.

But what we also know is that substance misuse, when we look at people who are long, who have long term dependency on substances, what we see is there's a disconnection. There's a sense of not being connected to your family, to your community. And but what Gabor Maté always says, and I love his book. If you haven't read it, read it.

It's "In the Realm of the Hungry Ghost." Substance dependency always originates in pain because the very same brain centers that interpret and feel physical pain become activated during the experience of emotional rejection. On brain scans, when you're looking at physical pain and emotional pain, they light up in response to social ostracism just as if they would if they were triggered by a physical stimuli. The hurt is at the center of all substance misuse and dependency.

Hurt is always it. So when we're looking at people who are chronically dependent, these are people who are suffering. And so our response to them should be through our humanity and compassion in patients. Which as many of you know, with people who are chronically misusing or dependence on substance, they're very prickly, and they can be really, really hard to be around, which is a trauma response.

Next slide. But we will always wanna come back to hope, and in fact, there is hope. Can we go to the next slide, please? All right, I'll just move on.

Hope is a really powerful medicine, and we know that trauma reactions may occur when there's a substantial perceived or actual threat. However, we also know that people often experience the same event and react very differently. Where one may be traumatized, others might be able to demonstrate greater resilience. In other words, it's not necessarily the traumatic itself that causes human distress, but rather the reactions to the traumatic event.

And what we can do is teach people how to be stronger, and resilient, and thrive. And so when we're looking at resilient responses to trauma, there are many resilient responses to trauma. In the previous presentation, they were, that's exactly what they were talking about. People with lived experiences of trauma have resilient responses to trauma.

And many people find healthy ways to cope with and respond to trauma and heal from trauma. Often people automatically reevaluate their values and redefine what is important after a trauma. And such resilient responses include increased bonding with family and community, redefined, or they redefine or increase their sense of purpose and meaning in their lives. They increase their commitment to a personal mission, revise their priorities, and increase charitable giving or volunteerism.

There's been some critique though about the term resilience because resiliency is defined really as like surviving extraordinary events. And we need to move beyond kind of being a resilient society and moving to a thriving society and addressing the social inequities that are contributing to human distress. So what we need to do is use information about biology and trauma to support people, support your clients, and provide a message of hope. They're not alone, they're not at fault, and recovery is possible and should be anticipated no matter how long it takes.

Trauma is something that happens to them. It's not who they are. You're having a normal response to an extraordinary event. Frame re-experiencing the events, hyper arousal, sleep disturbances, and other physical symptoms as psychological reactions to stress.

Communicate that treatment and other wellness activities can improve both health, psychological and physiological symptoms. That therapy, meditation, exercise, yoga, prayer, ritual, all of those things can help improve both our psychological and physiological symptoms of trauma. You may need to refer certain clients to a psychiatrist who can evaluate them, and if warranted prescribed psychotropic medication to address severe symptoms of trauma. Discuss trauma stress symptoms and their psychological components.

Explain that there are links between traumatic stress symptoms and substance use disorders if appropriate.` And again, normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, or being damaged, that they're not, quote unquote, crazy. Again, they are having a normal response to an extraordinary event.

So what we know works is that we know that what works are those who are fluent in many theories and treatment models, who are client centered and counselor driven, that are focused on strengths and protective factors, who are able to develop trusting therapeutic relationships. That's why we really, really like peer recovery folks because they're really, really good at developing trusting therapeutic relationships. We work within our area of expertise, and that culture is prevention. And I wanna talk a little bit about what does that actually mean?

And so a big part of it for us at the board is that we shift for moving around, like pathologizing these conditions, and that we start talking about health and wellness from a traditional indigenous perspective, which is centered in a holistic model. Whereas western perspectives are based in illness and disease. This includes philosophies that are equally considered the spiritual, emotional, and mental, and physical aspects of a person. Renee Linklater defines health and wellness as a mind body split, has been influenced by much of psychiatric thinking, and that we need to bring all of those back together and in balance.

Another facet, it includes other facets of life, including the environment, space, and time, and health of the earth. And so part of it is too, is when we look at indigenous ways of knowing, including the dimensions of caring, tradition, respect, connection, wholism, trust, and spirituality. Many American Indian traditions look at the medicine wheel to define wellness and seeking balance in the physical, mental, emotional and spiritual intersections of life. Indigenous philosophies are holistic in nature, which consider equally the physical, mental, emotional, and spiritual aspects of the human condition in relationship to our beloved Mother Earth and the land and resources, and Father Sky, which is our natural law, our ancestral wisdom, our connection to our great spirit and our ancestors.

So this is in contrast to Western philosophies which compartmentalize these aspects and rarely address or consider the spiritual aspect of the human condition. Indigenous models are based in wellness, while western models are concerned about disease. The diagnostic and statistical manual of mental health disorders defines mental health as, quote, a state marked by the absence of illness. Whereas indigenous philosophies understand mental health as a broad spectrum of challenges that people face in the walk of life.

American Indian elders and developers of the 49 Days of Ceremony conceptual framework. If we go down a couple slides to the medicine wheel. Yeah, there we go. That's where we're at.

Thank you. Wellness is what we talk about is from the 49 Days of Ceremony, which is a program we developed with two elders, Doug and Amy Modig, that talks about balance comes from wakening the will. And so within one self, while restoring balance within our, so we awaken the will within ourselves, which restores balance with our relationship with others, with Mother Earth and Father Sky. So wellness is related to our understanding of balance to one's self, family, and community.

And there are different things that we can kind of look to, including being in balance and in harmony, being in creation, care and compassion, and the challenges that American Indian communities contend with in the pursuit of wellness. What we wanna acknowledge is that, for us, we are sacred. The first part of any of the work that we do in acknowledging or waking that will is that acknowledging that we are sacred, that we are spiritual beings living in this modern world, and that in a lot of Western context, we don't talk about the spiritual aspects of the human condition, which puts us out of balance.

So the core part of this is to talk about us as spiritual beings and acknowledging that. Next slide. So what a lot of this means, there's a traditional, a very common traditional indigenous worldview is around relationships and the relational worldview. So everything is about relationships, our relationship with ourselves, with our family, with our community, with our tribe, with medicines, with our medicine people.

And so for health and wellness, what we wanna do is reestablish our relationship with medicine and change our relationship with medicine people. It's important that we develop a relationship with the spirit of substances. And if you're going to be using substances, whether it is for a prescription or prescribed reason, or if it's illicitly, you should develop a relationship with that medicine. Go into treaty with that medicine so that you're having a relationship with it, and then you understand better.

But it also means that we go into relationship with our medicine people, whether it's our medical providers, or whether it's our traditional medicine people, or just medicine people in our lives that we reestablish that. For me, over the last few years I've had to have a lot of oral work done, oral surgeries, and I was super grateful for opioids. I was very grateful for that. But I had a relationship with that medicine.

I went into treaty with that medicine, and I talked to my medicine provider about my concerns about the use of opioids in my recovery of these surgeries, and developed a relationship with them, and had a conversation. And I went into treaty with those medicines before I had my surgeries. And so what we wanna do is really like understand and reshape our understanding of these processes. Next slide.

And so the bottom line is that we can heal our communities through culture, through connection, and developing interventions and policies that are grounded in traditional indigenous knowledge, tribal based practices, as well as evidence based practices. And this is true for all conditions, whether it be substance use disorders, substance misuse, diabetes, cardiovascular, or psychiatric conditions as well. But we need to, address the broad spectrum of the lived experience of people to address these issues. And so with that, that was a lot of information I shared, and I wanna just, I do wanna open it up for some questions or comments.

I know that everyone is on.

- Thank you so much, Dr. Brown. And I'd like to invite our audience here to come to the microphone with any questions. And also of course we welcome additional questions online.

Dr. Brown, can you tell us more about your interviews with Choctaw women as they walked the Trail of Tears? What learnings resonated with you most during that project?

- Yeah, I'd be glad to. So that project I worked with Dr. Karina Walters and Dr. Michelle Johnson-Jennings.

And we received some NIH funding to develop and implement the Yapily project. And Yapily in the Choctaw language means to walk in silence or to walk with reverence. And so we created this intervention, reclaimed our traditional clans and our stories, and reclaimed our positions for women around being the givers and keepers of life. So it was a matriarchal project.

And so I also rewalked the trial with those women, and I had very close connections and ties to those women that I interviewed. And so I went back six months to a year after each of them walked, and I interviewed 25 women about their experiences. And there was a lot of common themes that came out of it. One was all of them talked about an experience of transformation, of being actually on the land where their ancestors walked.

And specifically there were two spots on the trail that we walked that the women had talked about these experiences of literally like physical transformation and being in relationship, like I said, with the land as well as their spirit. And so one of the things that we talked about a lot when we were on the trail, we used to say, we don't wanna get tied up in the drama of the trauma. We wanna reclaim our vision of health for future generations. And that was the name of my study.

So we were having like very like thoughtful conversations with women while they were on the trail to make sure that we weren't getting stuck in the drama of the trauma and that we were reclaiming those visions that our ancestors had. And through those conversations, that's where a lot of those transformations had. They also talked about connection to other Choctaw women and that being really helpful for them to be connected in their healing. A lot of women talked about that reclaiming that vision of health for future generations and really being concerned about the health and wellbeing of their children, and their grandchildren, and great-grandchildren.

And I'll say that, when we walked the trail, it's 570 miles, and we do it over nine days. And the women who really got into it and really participated intentionally through it at the end had a lot more kind of long lasting positive effects. But they talked about their love for their ancestors, for their future generations. There was one woman I talked to that I interviewed, when she was on the trail, she was over 400 pounds.

She had a agoraphobia, depression, high blood pressure. She walked every single day. She walked every single step. And every day she would say, "I hate it here.

I wanna go home." And every day I would say, "If you wanna go home, you can go home, but you need to coordinate your own travel home." And she would stay. There were some, one day I was like decompressing with her, and she was like, "I hate your face!"

And I was like, "I get it, but I'm glad you're here." I came back and interviewed her, and six months later, and she was a different person. She not only lost over 100 pounds, but just her whole experience and the way she held herself and presented herself was starkly different. She was like glowing pink, and she was like happy, and she was managing her diabetes and her high blood pressure with diet and exercise.

She had moved out of her mother's house, she was doing all kinds of different things and experiencing life in a way that she had never been able to experience before.

- Thank you, Dr. Brown.

- [Danica]

Are there more questions?

- Yes. This is connected to the previous question. Why is it, as we all know, a lot of people are having to access their treatment for substance use disorder outside of their community. Why is it so important that people have that access within their community in order to be successful on the path to recovery?

- I mean, that's an excellent question. I think one of the critiques of any treatment is that we tend to take people out of their social environments, their living environments, whether it be their family, or their home, or their community. We take them, we put them in treatment, tinker with them, and then we bring them back to the environment. And we never addressed any of the situations or conditions in the environment.

In some of our tribal communities in the Pacific Northwest, they have taken a community based effort and developed community interventions to address primarily the opioid and fentanyl epidemic. The Lummi Nation of Washington has, on every level of the tribal government, has implemented harm reduction and trauma informed care in the community. And so every person, every professional in the tribe, whether it's the tribal council, the police, the staff at the casino, everyone is trained in Narcan, and everyone. So there's a community wide effort, and they just built and dedicated a significant amount of money to develop to building a detox center.

Another tribe in the Pacific Northwest, the Suquamish tribe, developed probably one of the most innovative treatment centers I've ever seen in the country, not just in tribal communities. It's called (indistinct) And it's an integrated treatment program. And they, again, everyone is trained in trauma informed care. When they started this program, the first 18 months they had about an 80% success rate, which wasn't, which is great, which is amazing statistically, but it wasn't good enough for them.

So they went and interviewed the people who did not successfully complete their program and asked them why. And they said the stuff that we always hear. Transportation to treatment is a barrier. Housing is a barrier.

Food and access to resources is a barrier. So they developed or started building a transitional housing program. They bought a fleet of vans and everyone who, all of the van drivers are trained in trauma informed care, they pick people up and drop them off, and they go to the jail, they pick people up at the jail. They have elders in the facility.

They also offer traditional medicine including sweat lodge. They have acupuncture. They have all kinds of, but it's an integrated care program with the community. And so there's a lot of community events and connection to the community.

And they've been hugely successful in addressing the opioid epidemic in their community.

- Thank you, Dr. Brown. We have time for one more question, I think.

- [Danica]