Colonial Regimes of Mental Health,Substance Use,Drug Treatment,and Recovery: A Locally Contextualized,Anticolonial Response

Abstract

Documented in this article is the anticolonial treatment modality developed by a community-based behavioral health center on the island of O‘ahu, Hawai‘i—situated in a predominately Native Hawaiian community reacting to and affected by American colonial control of the Hawaiian Islands since 1893. We tie Haraway’s concept of “situated knowledges” to the methodology of Clarke’s “situational analysis” as a conceptual framing and a methodological approach in engaging the work of decolonizing health concepts and treatment regimens commonly taken for granted. Enfolding within that process the conceptual mapping for an indigenously informed way of thinking that emphasizes the relationship between colonizing “systems of care”—which emerge out of a sociocultural context of cultural domination that has broken down communally embedded Indigenous identities through individualism and exclusion or othering (i.e., hereafter abbreviated DIE)—and the need for decolonizing social processes that are in greater harmony with the rise of Hawaiian national consciousness (‘Olu‘olu) through communalistic notions of care (Lokahi) and nurturing cultural identities in balance with secular and non-secular relations anchored in historical and contemporary contexts (Aloha; i.e., hereafter abbreviated OLA). By increasing the convergence of OLA with the cultural mainstream of DIE as a unifying reference point applied to other Hawaiian and indigenous groups in both theory and praxis, this article is both a contribution to the social science of treatment, and to the literature on decolonizing drugs and alcohol.

Keywords

indigenous communities mental health treatment systems drug abuse substance abuse Hawaiian

Hawai‘i is an archipelago, which consists of eight major islands, several atolls, numerous smaller islets, and seamounts in the North Pacific Ocean that extend some 1,500 miles (with an additional 200 miles running along the outer lines of the archipelago in accordance with the Law of the Seas Convention) from the island of Hawai‘i in the south to northernmost Kure Atoll (Van Dyke et al., 1988). Hawaiians established themselves in Hawai‘i following years of exploration from Asia throughout the Pacific that the history of Native Hawaiians originates. According to the traditional Hawaiian Kumulipo chant, the genealogy of the islands’ people began before time, in what is known as Pō or darkness, and out of that darkness came light, the separation of the waters from the land, and the many living forms, including eventually the kanaka or people (Kamakau, 1992). The gods created the lands of Hawai‘i as well as the people who traveled to these islands and formed societies, becoming the Hawaiian people. These inhabitants’ (Nā Kanaka Maoli) ancient chants and other sources indicate that people were called Kanaka which means person, people, individual(s) which is also ancient based on the legendary mystical northern land called “Hawaiki” (Dudley, 1990; Fornander, 1996). They touched upon many lands including among the most isolated land mass in the world: Hawai‘i. Hawaiians conducted commerce with other Polynesians in the Pacific many years after arriving in Hawai‘i, and had infrequent contacts with Japan, the Great Turtle Island (today “North America”), South America, and other Pacific rim peoples. The people of these islands spoke a common language with some dialectic variations and followed common rules of conduct or kapu (prohibitions) that formed the social norms of conduct for this nation. The society was divided into a class structure of ali‘i (with authority due to a combination of mana, spiritual descent from gods or lesser gods), kahuna (priests), maka‘ainana (general people), and kauwa (lower level servants) (Kamakau, 1992).

Hawai‘i remained relatively unknown to Europe until the 25th of January 1778, when British Navy Captain James Cook arrived to find a highly developed society, kindling widespread knowledge of the islands and its people to the American and European world. Alcohol first made its way to the Hawaiian Islands with the arrival of Captain James Cook. In 1810, Hawai‘i became united as a nation-state under the unification of Kamehameha I (1779–1819). Missionaries began pushing anti-liquor campaigns with their arrival to the islands in 1820, fashioned as part of their mission to civilize Hawaiians (Tokishi, 1988). While some of them approved of wine or other alcoholic beverages consumed in moderation for themselves, alcohol use by natives was largely perceived as a hindrance to proselytizing efforts. These missionaries used moralizing rhetoric and fear-based messaging to dissuade Hawaiians from drinking, regardless of the amount consumed or its effects. Rather, they conceived alcohol as a moral imperfection and a conduit to heathenism, paganism, and savagery. The indigenous Hawaiian beverage, ‘awa was targeted first. ‘Awa is a non-alcoholic beverage made from the masticated (grounded into powder or chewed and spit into a bowl with water) root of the pepper plant (piper methysticum). In Hawaiian society, ‘awa was used medicinally, for religious and spiritual ceremony, for both sharpening mental faculties in times of political debate and legislating law (kapu), for dulling the faculties in times of relaxation and to release pain, both mentally and physically, and to lubricate social interactions (Kamakau, 1992). ‘Awa was non-taxable, often produced within a family or among very close associates, and not generally commercially produced. ‘Awa was central to the native Kapu religion and existing social order of the Hawaiian Kingdom (Kamakau, 1992), and like Fiji and elsewhere in the Pacific was subject to missionary hostility that “hoped to stamp out what they felt were pagan drug cults; and of colonial administrators [within the missionary bureaucracy], anxious to demonstrate that they, rather than the shaman, witch doctor or medicine man, were in command” (Inglis, 1975, p. 18; see also Tokishi, 1988). Despite the clear difference between ‘awa (no alcohol content) and alcohol, both in its content, method of production, and similarity and difference to the altering effect upon the consumer, anti-‘awa campaigns were zealously waged to give Christianity’s burgeoning emergence greater influence over native culture, and by extension, inexorable control of the Islands. ‘Awa as a cultural practice was too entwined with traditional spiritual beliefs for missionaries to tolerate it, and so it was ‘awa among natives especially for “ceremonial occasions that the missionaries deplored” as the devil’s vice (Inglis, 1975, p. 59). In North America, Europeans observing the social turmoil caused or aggravated by drunkenness heightened their belief that alcohol could unleash native violence toward them (Mancall, 1995); hence, it was in the colonists’ self-interest to…discourage the sale of spirits (Inglis, 1975, p. 59). By the 19th century, the U.S. government banned the sale and trade of liquor to Indigenous tribes but allowed Europeans to flood “Indian country” with alcohol unabated and with impunity (Unrau, 1996). Prior to Indigenous American tribes being neutralized and their autonomy converted to domestic dependence or wards of the state (Byrd, 2011), however, during westward territorial expansion when Indigenous Peoples represented the greatest threat of resistance to colonial settler dominance, the alcohol trade was aided by the U.S. government and allowed to flourish (Dempsey, 2002; Mancall, 1995).

In Hawai‘i, the Native Hawaiian government attempted to combat the trafficking of alcohol to Hawaiians through public policy while simultaneously avoiding draconian punishments and the over-incarceration of Hawaiians (Williams, Makini, et al., 2021). Instead of targeting Native Hawaiian users, the kingdom regulated the commercial trade of alcohol, attempting to prevent European powers from inundating the Islands with alcohol (Williams, Makini, et al., 2021). Unlike the indigenous Hawaiian beverage, ‘awa, Inglis (1975) notes that alcohol’s function as an intoxicant “was in the colonists’ self-interest to encourage it” (p. 59) as it would “take away understanding” (p. 29). Inglis (1975) adds, alcohol “removed a man from the cares of the world, without precipitating him into another. Although his behavior when in this condition might be anti-social and dangerous to himself and his companions, it presented no real threat to the authority of Church or State” (Inglis, 1975, p. 29).

According to Williams, Makini, et al. (2021), within the Hawaiian kingdom, the government cracked down on business establishments selling alcohol. While the justification for these restrictions were initially in line with the Christian influence from European missionaries, by the mid-1800s, the Hawaiian government focused instead on the social costs of alcohol and its detriment to the collective health and well-being of the Hawaiian nation. Despite these multiple efforts, consumption of alcohol did not cease. In light of monotheistic inspired cultural oppression of Hawaiians and the attendant acceleration of economic, religious, and political structural changes on the fundamental hierarchical organization of society, in fact, alcohol would displace the indigenous Hawaiian beverage, ‘awa, in the enactment of traditions—a practice that managed to persists over generations in a segment of Hawaiian families (Alu Like, 1989a, 1989b). Considering missionary investments in transforming Hawaiian society from what they perceived to be a pagan society to a God-fearing civilization, it was not uncommon for Christian missionaries to remain even after their formal missions were terminated, taking important roles in Hawaiian society (Merry, 2000). Sailors from Europe and North America married into Hawaiian families and became part of the Hawaiian society, while Chinese and Japanese laborers came to work on sugar plantations or accompanied such workers (McDermott & Andrade, 2011). Many others, including those of African descent and other Polynesians also established homes in Hawai‘i (Jackson, 2005). As they did this, many renounced their former citizenship and took up Hawaiian citizenship (see also Husted, 1892). Immigrants from all parts of the world came to Hawai‘i. The ensuing global influx to Hawai‘i coincided with trade exchanges between Hawai‘i and China, Great Britain, and the United States as well as other nations (Gonschor, 2019). In 1840, Hawai‘i’s first written constitution was passed, containing a declaration of rights often referred to as the Hawaiian Magna Charta, that effectively transitioned the Hawaiian state from an “absolute monarchy” to a constitutional monarchy (Sai, 2013). For the next 70 years, the kingdom transformed from an elitist society based on the rule and rank authority of ali‘i and kahuna to an egalitarian one in which high-ranking chiefs and commoners were viewed as equal before the law (Osorio, 2002). The government also developed a system of schools, boosting Hawai‘i’s literacy rate to one of the highest in the world (Schmitt, 1977). It was a modern society with a public health system, and even had electricity and telephones at its ‘Iolani Palace before the U.S. White House. Its international stature as an independent nation was without question, holding treaties and executive agreements with almost every nation-state that existed at the time (Hawaiian Islands, 1887): from the German Empire to the lesser known country of Bremen, and from the imperial superpowers Great Britain and the United States to the former imperial powers of Portugal and Spain. From 1810 until 1893, Hawai‘i underwent many changes in its political formation, economy, demographics, educational quality, and international presence (McGregor & MacKenzie, 2014). Hawai‘i was undergoing its course of development, unfolding into its markets, capital, resources, labor, and land a future fashioned on its own internal culture, hopes, and dreams for its future so that by1892 it was a vibrant multi-racial, multi-cultural nation engaged in intellectual and economic commerce throughout the world (Gonschor, 2019; Husted, 1892), but due to outside forces this development did not continue.

Avaricious desire for wealth and power among remnants of the Christian missionaries, who aligned with U.S. military interests, resulted in a conspiracy to land U.S. forces in Hawai‘i, wresting the power from the constitutional monarch, Queen Lili‘uokalani, and placing it in the hands of the “Missionary Boys,” who then became known as the Provisional Government (Dudley & Agard, 1990). The Provisional Government (PG) attempted to cede Hawai‘i to the U.S. in a treaty of annexation, but President Cleveland intervened and rejected the treaty. Previously formed by proclamation, the PG ratified a self-serving constitution, blocked the vast number of Hawaiians from participating, changed its name to the Republic of Hawai‘i, and resubmitted another annexation treaty when a new President, McKinley took charge 4 years later. The treaty was again resisted by widespread Hawaiian protest (Minton & Silva, 1998) as well as by those in the U.S. who recalled Cleveland’s Congressional address (Cleveland, 1893). Realizing the “treaty” could not get the 2/3 Senate approval required of the U.S. Constitution, the conspirators circumvented that requirement and settled for only a joint resolution of Congress, known as the Newlands Resolution, which, over the outcry of the vast majority of people passed on July 7, 1898 (30 Stat. 750; 2 Supp. R.S. 895). The McKinley administration circumvented the constitution (Art. 2, Sec. 2, Clause 2, U.S. Constitution) and declared Hawai‘i annexed by a joint resolution of both houses of Congress (Richardson, 1908). It took up a third of the Hawaiian lands for its military and imposed its colonial control over all public education, travel outside of Hawai‘i, and international trade. In addition, the U.S. president appointed a territorial governor, all judges to courts, and instituted taxes on the Hawaiian people. The United States would obtain the choicest lands and harbors for their Pacific armada. Queen Lili‘uokalani’s protests that the occupation was a breach of treaties and international law were simply ignored (Laenui, 1985; Lili‘uokalani, 1898).

When the United Nations was formed in 1945, territories such as Hawai‘i were to be given three options: independence, free association or integration (UN Charter, Article 73; UN G.A. Resolution 66(1) 1946). The United States took no action toward the option of independence or free association, leaving only integration as the “choice,” i.e. remaining a territory of the U.S. or become the “State of Hawai‘i” (Admission Act of March 18, 1959, Pub L 86-3, 73 Stat 4; see also Laenui et al., 2020). In 1993, the U.S. adopted an apology resolution (Pub L 103–150, 107 Stat 1510)—echoing the sentiment of president, Grover Cleveland (Gillis, 1897)—admitting its wrongdoing 100 years after the Queen’s government was overthrown. The “Apology Bill,” as it became known as, was symbolic in meaning but without legal traction in the court of U.S. law, so although granting a major concession that validates the grievances of Native Hawaiians was welcome, legal, and just, it does little to assuage the material realities faced by Hawaiians as a consequence of the illegal overthrow of the Kingdom (SB 2899 & HB 4909, 106th Congress, 2nd Session).

With its conversion into a U.S. territory in 1900, and subsequent U.S. occupation under “Hawaii State” pretenses at current, “Vital statistics by the Americanized Hawai‘i government since 1900 have persistently demonstrated Native Hawaiians to have the worst health profile in the islands, with the shortest life-expectancy, highest mortality rates and greatest rates for most chronic diseases” (Blaisdell, 1989, p. 13). Hawaiians are “over-represented at every stage of the criminal justice system” (House Concurrent Resolution 85 Task Force, 2017, p. 3). As a result, there is disproportionate representation of Native Hawaiians in drug treatment and mental health services (Chesney-Lind & Merce, 2020; E Ola Mau, 1985; House Concurrent Resolution 85 Task Force, 2017; Kassebaum, 1987; Office of Hawaiian Affairs [OHA] et al., 2010).

Anticolonial Praxis

Conceptual Framing

Hawai‘i’s colonial history has shaped the collective consciousness of Native Hawaiians. The historical and contemporary context for community cultural programming is influenced by cultural codes which form in the collective subconscious of the Hawai‘i society that define what is right and wrong, what is moral and natural, and which forms of behavior are appropriate in any given circumstances (Laenui, 1997a). Such codes can be found in all societies, and are formed from myths and legends, deep national memories, environmental conditions, and internal conflicts, along with a multitude of other processes that occur over long periods in a society (Laenui, 2013). Such codes are not found in any constitutive document; rather, they are unwritten and usually unspoken. Yet they are so ingrained in a society that they become its very driving force. Often observable, these norms and beliefs are found in the routines and habits of people, in their fears and pleasures, their dreams and expectations, and in their systems of reasoning. In Hawai‘i, at least two distinct deep cultural streams have formed that touch on every area of life. One is prominent in the formal and the other in the informal systems of community life. The first of these cultural codes, identified by the acronym DIE (Domination, Individualism, and Exclusion; Laenui, 1997b), is emblematic of the Americanized social order in the Hawai‘i islands as a multiethnic colony (Baumhofer & Yamane, 2019; Fojas et al., 2018; Fujikane & Okamura, 2008; Irwin & Umemoto, 2016; Kaholokula et al., 2020). Situated in Hawai‘i’s colonial history, American systems in Hawai‘i have been heavily reliant on Dominance (Americans of European descent commonly rejected the idea of non-white Hawaiian rule; see Kamakau, 1992; Kuykendall, 1947), Individualism (where self-promotion is the vehicle of success; self-interest is pursued at the expense of in-group and community welfare; and social prestige is tied to individual material wealth accumulation), and Exclusion (such as suppressing the Hawaiian language; influencing the democratic process by limiting voting rights to property owners and men; excluding Hawaiians from positions of administrative power and bureaucratic authority; and embracing mainstream institutions designed to serve non-Hawaiians)—henceforth referred to as DIE deep culture. This DIE culture was overlaid upon the preexisting OLA (‘Olu‘olu, Lōkahi, and Aloha) culture, which was based on ‘Olu‘olu (maintaining a caring regard for others), Lōkahi (working toward a common goal promoting the betterment of society that deepens the commitment to ‘Olu‘olu), and Aloha (welcoming the inclusion and collaboration of different cultures, beliefs, ideas, and philosophies to strengthen communities, families, the environment, and social institutions as a whole)—which continues to survive, and which has been making a recent comeback as part of the conscientization and decolonization efforts of Hawaiians. DIE governs the formal systems, and OLA is the informal system of Hawai‘i in terms of the cultural codes found in the collective subconscious of Hawaiian society, which has bearing on what is right and wrong, what is moral and natural, and what forms of behavior are appropriate in given circumstances (Laenui, 1997b).

Consequently, the origins of Hawai‘i’s formal social service system (ca. 1852; i.e., the Stranger’s Friend Society which was similar to the Salvation Army) and mental health system (ca. 1866; i.e., Insane Asylum of O‘ahu), as previously documented in the collective work of Catton (1940), Chung (1955), and Garcia (1972) was modeled after American-style institutions in the local setting, which was lobbied for by Americans in Hawai‘i and ultimately created in the same mold as low-income countries that import Western “experts” and psychiatry, social work, and, more broadly, Western social service ideology, practice, and theory (Higginbotham, 1987). As documented by E Ola Mau (1985), Hawai‘i’s mental health system evolved under the dominant influence of a white western American ethnocentric professional composite profile, as well as the bureaucratic drive of the health system to systematize its procedures, consolidate its authority, and supervise its resources. The regulatory features of the system left no room for cultural diversity and did not encourage minority leaders to construct treatment methods. The poorly resourced system sought to mirror mainstream American institutions, and in doing so replicated U.S. institutional procedures, practices, and philosophical premises. It thus failed to connect with Hawai‘i’s sociocultural environment and could not respond to the culture-specific health needs of Native Hawaiians, the dominant population when these programs were established (E Ola Mau, 1985).

Methodological Framing

We adopted the qualitative research methodology of “situational analysis” (Clarke et al., 2018). Situational analysis is a critical research methodology which takes as its unit of analysis the concept of the situation, which can (a) illuminate the complexities of social situations and their surroundings, even as they stabilize or change and form new patterns and positions, (b) enhance marginalized perspectives and uncover subjugated knowledges, and (c) empirically displace “the knowing subject” (Clarke et al., 2018). Situational analysis creates “the situation” empirically by using three ecological-relational maps to support the analysis and research design: (a) situational maps, (b) social worlds/arenas maps, and (c) positional maps (Clarke et al., 2018). The “situation” or unit of analysis as we define it is the production of a locally developed and anticolonial treatment modality conceived by Hale Na‘au Pono [HNP; House for Inner Balance], a community-based treatment agency generated in response to conditions within which it continues to operate. The conditions of the “situation” comprised elements in relation to the first author’s personal experience as an Indigenous Hawaiian legal scholar and grassroots activist as well as both authors’ depth and breadth of professional experience in the behavioral health field, and as direct participants in Native Hawaiian communities. In the situation map, we specify the following elements: political/economic, local to global, organizational/institutional, major contested issues, human/nonhuman, spatial and temporal, sociocultural/symbolic, discursive constructions of individual actors and collective human actants, nonhuman elements, and implicated/silent actors/actants, as well as individual and collective elements. Such elements are necessary for community-based treatment centers to develop a treatment modality that is engaged in the work of decolonizing behavioral health, mental health, and alcohol and drug services. For example, the historical and contemporary context such as the hotly contested issue of illegal annexation here are important spatial and temporal elements that have shaped the spatial concentration of Hawaiians within the Wai‘anae catchment area as well as behavioral health services in Hawai‘i. The social world map is situated on a much smaller area of Hawai‘i, within the arena of the Wai‘anae Coast (spanning roughly 22 miles in length and approximately 9 miles in width). Here, the social worlds of staff interactions with mostly Hawaiian clients are collectively integrated with the second author’s experience as a clinician at both a culture-based treatment program (not HNP) and a treatment-as-usual program; all three agencies (including HNP) were operating simultaneously along the Wai‘anae Coast. The positional map enables us to consider how the extremes of each position affects views of “the situation.” One position is that Native Hawaiian consciousness is an integral component of sustaining long-term abstinence and affecting lasting community change reaching family systems, while the other is that a general recovery identity should take primacy in treatment programming. The second extreme position believes that treatment efficacy is strongest when addiction education emphasizes “standard” risk and protective factors over incorporating education on historical trauma, native traditions and cultural practices. Taking these positions together, we posit the following hypothesis: alcohol and drug services in Hawai‘i need to take account of and be accountable to the ways in which domination has worked through individualism and exclusion or othering (e.g., DIE) and need to work in greater harmony or convergence with OLA to improve the effectiveness of service delivery to Native Hawaiians. In buttressing our hypothesis, the first author’s empirical experience as the Director of Hale Na‘au Pono has been synthesized with the second author’s specialized knowledge wedded to direct clinical practice, as individual and collective “discursive actors” (Clarke et al., 2018) brought into this article. Data in the form of previously published research directly related to “the situation” by both authors (see reference section), as well the authors’ notes as practitioner-researchers, respective program materials, and informal discussions with staff (former and present), clients (some of whom were service recipients at all three treating agencies along the Wai‘anae Coast), and family and community members, have helped to construct our situation analysis.

Analytic Framing

Since the 1960s, a vibrant development of indigenous and Hawaiian national consciousness has occurred that has attempted to reclaim historical losses in land, language, power, status, resources, and culture due to the controlling colonial influences and attendant displacement of Hawaiians. Hawaiian activists have decisively challenged the sanctity of American entitlements across the world and the superiority of moral stature in U.S. territories in pushing back the colonial dominance of social and cultural institutions bureaucratically governing Hawai‘i (Laenui, 1993). Hawaiian communities have attempted to disentangle the cultural strands of DIE choking the life domains of “urban planning and development,” education, health, income and wealth. Political disenfranchisement, acculturation stress, and ethnic marginality are correlates of Hawaiian identity positioned within a lower strata of society beset with indicators (poverty, unemployment) for qualitative distress associated with negative statistics and a higher overall risk burden for mental health problems (Baumhofer & Yamane, 2019; Fojas et al., 2018; Fujikane & Okamura, 2008; Irwin & Umemoto, 2016; Kaholokula et al., 2020). This Hawaiian cultural awakening has underscored questions and implications related to Native Hawaiian self-determination, independence, and sovereignty (Laenui, 1996). According to extensive archival research conducted by an eight-member task force sanctioned by Alu Like, Inc., a Native Hawaiian community advocacy organization, on the historical development of Hawai‘i’s mental health system:

In 1963 Hawai‘i became eligible for a $50,000 federal grant-in-aid to begin planning for a statewide comprehensive community mental health system. Over 375 lay and professional volunteers had the opportunity to shape the character of Hawai‘i’s system for future generations, following general federal guidelines. These volunteers crafted some 288 recommendations working through the State Planning Committee, Country Steering Committees, and 55 special task forces, and under the sponsorship of Dr. Leo Bernstein, the state’s Director of Health. Nowhere in the report were ethno-cultural considerations mentioned in sections dealing with training, consultation, diagnosis, treatment, rehabilitation, facilities development, or special programs. (p. 121)

In mental health treatment, the momentum of Hawaiian activism spurred an awareness of the disproportionate representation of indigenous Hawaiians both in the criminal justice system and behavioral health services. Indigenous communities realized the increasing importance of differentiating behavioral health from colonial systems of care galvanized through Hawaiian interest advocacy groups and organizations raising questions concerning primary and behavioral healthcare, particularly due to the case of Hale Na‘au Pono (HNP), a community-based treatment center. HNP emerged in Wai‘anae on the Island of O‘ahu—a community of the largest number of Native Hawaiians in Hawai‘i. It aimed to develop a locally contextualized and anticolonial response to community alcohol and drug problems and mental health concerns that have traditionally been treated by behavioral health models pervaded by DIE cultural elements, endeavoring in the process to highlight and unify a collection of experiences, practices, readings, discussions, and consultations by Indigenous practitioners and community members locally situated and affected by the history of American colonization of Hawai‘i. This contemporary orientation was crucial to HNP’s conceptual framing, methods, analytical approach, and contribution to knowledge, all of which were distilled into the training materials it developed for its Adult Mental Health division. Arising out of this approach was the earlier stated hypothesis informing service delivery, which was based on knowledge in line with Haraway’s concept of “situated knowledges” (1988). In essence, Haraway (1988) argues that what may be considered “common sense” knowledge to one social group (Native Hawaiians) may be situated differently in the sense of being too abstract or opaque to the lived experience and collective consciousness of another group (Non-Hawaiian administrators governing Hawai‘i’s health bureaucracy), rendering such “common sense” knowledge esoteric. This is in large part due to strong oral traditions that have kept Hawaiians in touch with the pain, anger, trauma, and contemporary grief of “history.” Along the Wai‘anae coast on the island of O‘ahu, Hawaiian communities serviced by HNP were acutely aware of the impact of European Americans’ arrival in the Hawai‘i Islands. While Hawaiians accommodated foreigners, Hawaiians were nonetheless subject to cultural invasion manifesting in: (1) the manufactured supremacy of European American colonial values generally regarded as irreproachable by Europeans (Bushnell, 1993; Merry, 2000); (2) European American culture as expressed through the formal bureaucracy of government, health, education, courts, and the social services and business sectors subordinated and inferiorized Hawaiian ways of thinking, believing, and behaving (Kame‘eleihiwa, 1992; Kuykendall, 1947, 1953, 1967; McGregor & MacKenzie, 2014); (3) Hawaiian cultural practices being systematically and systemically demeaned, devalued and denied and subsequently crusaded against via de jure discrimination and de facto racism (Baumhofer & Yamane, 2019; Bushnell, 1993; Kassebaum, 1981; McGregor & MacKenzie, 2014; Merry, 2000); (4) rapid changes in Hawai‘i’s economy that introduced currency tied to the rise of sugar and pineapple plantations, resulting in the displacement of internally independent agricultural production and increasing dependence on foreign goods and imported food (Kimura & Suryanata, 2016); (5) capitalistic growth, taxes, and market-based exchanges and transactional relationships coinciding with the relegation of Hawaiians to the ranks of the unemployed, impoverished, houseless, and those that resided in crowded, substandard housing (Kuykendall, 1947, 1953, 1967; McGregor & MacKenzie, 2014; Osorio, 2002); (6) deteriorating mental health and physical illness corresponding to the transformation of the traditional sociocultural context, which marked Hawaiians as ethno and culturally different (E Ola Mau, 1985); and (7) the forceful stripping of Hawaiian control away from the kingdom government, culminating in the U.S. invasion of the Hawai‘i Islands in 1893 (Sai, 2013). Such history is intergenerationally passed down through familial lineages and spread through large community networks tightknit with fictive kin bonds and familial-engendering ways of relating (e.g., Hawaiian adolescents are taught at a very young age to refer to a male family friend as “uncle.” They also learn to internalize the Hawaiian value of referring to “strangers” within their immediate community and outside of it inclusively as “aunty,” “grandpa,” etc.). Thus, for the Hawaiians operating HNP, the knowledge that came out of this impact of colonial invasion was situated in “common sense” and deemed to have mental health implications, given its correlations with resentment, anger, resignation, withdrawal, unresolved grief, trauma, depression, unhealthy sense of ethnic identification, unesteemed cultural heritage, and negative behavioral health outcomes. HNP therefore adopted an OLA cultural care model applied in an indigenous context, which centralized the cultural views of the community and family, emphasized spirituality and the environment, and adopted general models such as Ho‘oponopono (discussed later). This model emphasized that behavioral health, mental health, and alcohol and drug services in Hawai‘i needed to take account of and be accountable to the ways in which the colonization process via domination has worked through individualism and exclusion or othering (e.g., DIE) and work in greater harmony or convergence with OLA. The “two deep streams” of DIE and OLA comprise a conceptual framework that is useful for thinking about the relations between colonizing and decolonizing social processes.

Our view then, is that decolonization programs call for a consciousness of the political realities of colonization and must work to understand how to undo such “realities” in a milieu that encourages and supports the development of Hawaiian consciousness. Alternative cultural practices, environmental awareness, variety of food consumption, awareness and appreciation of land and ocean, and one’s own indigenous awareness are helpful in the recovery process. However, unless these aspects are attached to a specific awareness of the colonization and decolonization process, they are not a complete program for decolonization. If such alternative programs fail to focus on understanding DIE and OLA, the applicability of these alternative practices, and awareness of deep cultures, behavioral health, mental health, and alcohol and drug services are liable to end up ingraining the client deeper into both the existing deep culture and the colonial structures which have overtaken their society. This means that such programs will simply continue the colonization process with a softer, kinder, gentler approach, like a soft velvet glove wrapped around an iron fist.

DIE Culture in Contemporary “Systems of Care”

On October 31, 1963, President John F. Kennedy signed into law the Community Mental Health Act (also known as the Mental Retardation and Community Mental Health Centers Construction Act [henceforth referred to as the Act] of 1963), which was designed with the intent of “deinstitutionalization” and concurrent investment in building up Community Mental Health Centers (CMHCs). This marked a new era of mental health service delivery that reintegrated hospitalized and institutionalized individuals who were struggling with mental health-related concerns back into the community rather than placing them in prisons or other state institutions responsible for the “transcareration” phenomenon in the U.S. CMHCs were designed to provide an outlet for individuals in the surrounding community who needed stabilizing services in order to avoid the (re)hospitalization and (re)incarceration that resulted in the wholesale warehousing of people with mental illnesses.

In accordance with the Act, HNP, a CMHC, used a clinical community-based approach to behavioral health needs concentrated on mental health and drug treatment service needs in order to develop a program to meet the wide needs of clients, including housing, a certified Clubhouse (ICCD; psychosocial services), group therapy, and an underlying cultural services component based on its Voyage to Recovery Program centered on illness management. All services were nationally accredited by CARF and included both children’s and adult services; behavioral health for the SMI population (outpatient services, psychiatric services, nursing assistance, case management services, peer support services, client visits at their homes); housing, including 8- to 16- and 24-hour services; and financial management of clients’ funds. In the children’s services, HNP managed a housing program through its specialized foster homes services, supported by a psychiatrist, psychologists, and case managers, and provided special training for parents of such foster homes. It provided after school services for its clients, as well as a special school, Adolescent Day Treatment Centers, where students attending the center were able to receive graduation credits. In providing the broadest array of services, the State supported HNP at a time when it could not take care of the very “special needs” kids and instead shipped them out of Hawai‘i to the continental United States for care. When there was an outcry to bring Hawai‘i’s kids back home to our communities, the State turned to HNP, which accepted the largest number of returned kids. In other words, the State seemed to fund HNP only when it was considered by the public as having failed to meet the needs of this special population.

Based on the Act, states are supposed to ensure a functional community mental health center—whether free-standing or interdependent on a combination of private, governmental, or nonprofit health facilities and treating agencies. Reports issued by the Hawai‘i Mental Health Core Steering Committee (2020) note the historical failure of the State to create properly funded CMHCs. In Hawai‘i, every CMHC is State operated and controlled, except for Hale Na‘au Pono. However, in direct violation of the Act, the State entered the Wai‘anae community to compete as a CMHC, formed its own Clubhouse, brought housing services into the community, and essentially destroyed the operations of HNP as the large comprehensive behavioral health center it was. The State of Hawai‘i has continually struggled with control over the provision of services, choosing instead to secure its own needs by ensuring funding for inadequate mental health clinics designed to compete against and take over community-developed CMHCs. Consequently, HNP was defunded as an outpatient center under the Adult and Children’s Mental Health Division and forced to compete with other private for-profit and nonprofit organizations across the State of Hawai‘i, in violation of the spirit of the Act. Historically, HNP had received its primary funding from the Department of Health, but those funds were insufficient to meet the requirements for programs the State called for. HNP thus had to compete against State operations and services by the State, which themselves did not meet the State’s own high requirements (i.e., CARF accreditation for all behavioral health services or ICCD accreditation for psychosocial programs such as clubhouses). For instance, the State operated clubhouses, but made exceptions for their failure to meet national standards of performance, while requiring other clubhouses to be nationally accredited under CARF or Clubhouse accreditations. An example is found in Makaha on the island of O‘ahu along the Wai‘anae Coast, where the State operated a CMHC less than 5 miles from HNP’s clubhouse in order to compete with HNP. The State’s treatment of HNP illustrates how dominant notions of “behavioral health” in Hawai‘i characterized by DIE culture are contrary to the anticolonial-informed cultural roots in the Indigenous community’s conception of OLA care models (see comparative Tables 1 to 4).

Table 1.

Colonial Ideas of Recovery Versus Indigenous Care Models.

DIE	OLA
Unit of target: individual is the focal point	Unit of target: individual is a member of a community within a larger family of a nation
Recovery: operationalized as an individual unit of metric: e.g., number of days free of alcohol and other drug abuse or disorder	Recovery: individual recovery takes place in the balanced substrate of family well-being, community health, and the reclamation of nation
Brick-and-mortar office-based interventions	Family and community health interventions present decolonization consciousness as a spiritual additive to the overall treatment
“Three strikes and you’re out” disqualifies a client for further services	Hale Na‘au Pono is a house of forgiveness and continual improvement

Source: Blume, 2020; Duran, 2019; Duran and Duran, 1995; Laenui, 2000b, 2007; Linklater, 2014; Muller, 2020; Rezentes, 1996; Thatcher, 2004; Williams, Laenui, et al., 2021; Williams et al., in press.

Table 2.

Colonial Ideas of Substance Use Versus Indigenous Care Models.

DIE	OLA
Root cause is one of genetic predisposition	Social, economic, political, and other determinants of health largely account for the variance in outcomes
Addiction is a moral and cultural failing requiring the (re)habilitation of values	Addiction is a byproduct of societal failure and lack of access to resources, power, and wealth; poverty, oppression, discrimination, homelessness/houselessness: i.e., counterproductive behavior is the vicissitude of adaptation to scarcity and deprivation
Indigenous ways of knowing, being, and doing as treatment philosophy and a professional code of conduct/ethics are excluded, if even fleetingly considered	Indigenous truths are included in pedagogies, curriculum, praxis, precept, protocol, example, and other facets of treatment
Symptom of bad habits and poor cultural resources: hence the need to learn how to balance a checkbook and undergo “cultural healing”	Symptom of historical legacy of colonization on the total social system of individual

Source: Blume, 2020; Duran, 2019; Duran and Duran, 1995; Laenui, 2000b, 2007; Linklater, 2014; Muller, 2020; Rezentes, 1996; Thatcher, 2004; Valentine, 1971; Williams, Laenui, et al., 2021; Williams et al., in press.

Table 3.

Colonial Ideas of Drug Treatment Versus Indigenous Care Models.

DIE	OLA
Mandates and coercive duress manufacture a “substance abuse” treatment population of clients	Operates on the principle of attraction: people desire sobriety why they feel they have good enough reason to; treatment is about bridging the gap between reason and attraction
Client values are a self-perpetuating system of pathological, unhealthy, dysfunctional behaviors and attitudes	Attitudes are shaped by functional adaptation to dysfunctional, unhealthy, and pathological social, political, and economic societal structures
Modalities, curriculum, policies and procedures, professional etiquette based on middle-class ideals encapsulated in “treatment”	Hale Na‘au Pono, e.g., changed the “professional” language to the local English vernacular, which included a mixture of Hawaiian and other ethnic wording
Class-race conflicts and patriarchal norms normalized in “systems of care” under the guise of professionalism, codes of ethics, rules and regulations	Social, political, economic, and DIE cultural structures are confronted, challenged, and militated against in the language of OLA to better “care” for Hawaiians within “systems of care”

Table 4.

Colonial Ideas of Mental Health Regimes Versus Indigenous Care Models.

DIE	OLA
Cultural health beliefs are taken for granted as all psyches are created equal: racialized colonial propaganda and oppression are denied, rejected, and omitted as an internalized reality of Indigenous mental health	Cultural history, language, music, story, protocol, concepts, beliefs, and healing traditions—Nā Mea Hawai‘i (Hawaiian Ways)—are explored, validated, recognized, and honored as part of the architecture of the psyche and dimension of mental health
Cultural practices are highly flawed in actual practice and reify stereotypes of the primitive native: mostly symbolic for State and federal grant funding; cultural experts are unpaid volunteers	Cultural practices are supervised and monitored from the top-down and cultural experts are properly paid for their valued service
In workshops, professional training webinars, seminars, and the workplace, cultural humility, -competence, -sensitivity filter Indigenous experiences through monocultural dominant biases. e.g., low overall rates of voluntary Hawaiian community involvement in “systems of care” viewed as something other than the possibility of a collective cultural resistance to further haole (foreign) dominance	Cultural humility, -competence, -sensitivity give voice to Indigenous voices, ultimately increasing the potency and potentiality of actual systems change, i.e., silencing, rejecting, extracting, denying, and withdrawing DIE cultural elements
Focus on mental health individuation: psychosocial centric treatments	Focus on community, family, cultural identity, and nation as means of generating improvement in individual mental health

The Constitutive Cultural Elements of DIE “Systems of Care”

Domination—This element is reflected in the formal economic, education, political, military, and judicial systems. Central to this colonialist characteristic is the idea of expansion in terms of an ever-widening territory, market, or other field of conquest as part of the natural order of things. Colonialism has for years led Indigenous Peoples to believe they are outside of, and unwelcome in, mainstream culture, while also diluting traditional Indigenous influence (Blume, 2020; Duran, 2019; McKnight, 2003; Muller, 2020; Saggers & Gray, 1998; Steinberg et al., 2004). Williams et al. (in press) argue that this social control and cultural containment structure reflects the multiethnic dominance of the State bureaucracy extending its governance to colonial-induced poverty, inequities, and over-incarceration, which has synergistically contributed to the systemic and systematic “clientization” of, or the constant churning of predominately darker-skinned and lower-class Hawaiian people through State institutions and treatment agencies (OHA, 2019). As a result, Hawaiians voluntarily entering into substance abuse treatment is regarded as an act of self-subjugation and capitulation to multiethnic dominance and control. Williams et al. (in press) hypothesize that Hawaiians are grossly overrepresented as court referred subjects of “treatment,” driven into the State’s human services and social welfare systems not by qualifying medical necessity but by the non-medical dictates of its criminal justice apparatus (OHA, 2019; OHA et al., 2010). They further assert that Hawaiians themselves have now been effectively colonized by virtue of being redefined through State imprimatur as “clients,” “consumers,” and “patients.” These human bodies signifying value are reconstituted as Medicaid-sponsored commodities who are integral to the fiscal viability of many public (and private) substance abuse treatment and behavioral health programs, thereby stimulating growth of the State’s economic dependence on the service sector industry by producing a professionalized workforce “serving” and “treating” Native Hawaiians (see also McKnight, 1995). At the same time, since Medicaid is a publicly funded program, the commodification of more members (whether Hawaiian or not) increases expenditures and is more expensive for federal and State agencies. Hawaiians are also drastically overrepresented in the State-sponsored substance use treatment system at a rate of 43.8%; over two times higher than expected given the overall population size (Kim et al., 2017). Due to the imposition of the criminal justice system, most Hawaiians in mental health service systems are there on account of mental health court or judicial referral. Treatment service records, however, do not paint an accurate picture of the prevalence of substance use disorder among Native Hawaiians, since they are measured against populations that are less heavily policed and less likely to be issued a court order for treatment. This overrepresentation of Hawaiians in substance abuse treatment programs does not reflect the actual rate of “substance abuse.” Rather, it is due to their harsher treatment at the hands of the judicial system and a referral system that relies on coercive pressure from the courts (Kassebaum, 1981; OHA et al., 2010). While drug use surveys suggest Hawaiians have a higher rate and initiation at an earlier age (Hawai‘i State Epidemiologic Outcomes Workgroup, 2020; Okamoto et al., 2019), it is erroneous to cite drug use statistics to claim that Hawaiians are overrepresented in treatment programs because they are more likely to lose control and “abuse” drugs,¹ thereby deserving criminal justice intervention, as opposed to these statistics being associated with minority group stereotypes and the racial-ethnic-cultural oppression of Hawaiians (Kaholokula et al., 2020). This is because drug use statistics are usually decontextualized and prone to misinterpretation based on the mistaken idea that drug use is a cultural trait of a colonized outgroup (commonly described in the early 19th century as “big, strong people, very dark or black-brown with flat noses” [Jensen, 1996, p. 112]) rather than a sociopolitical phenomenon (Helmer, 1975). Drug use surveys, for instance, fail to indicate how many Hawaiians were past or current users with active or resolved substance use disorders and whether such use was in context of acculturative stress or societal pressures to conform to non-Hawaiian ways of thinking, doing, acting, and achieving. Further, substance use data are not adjusted for the population distribution in each catchment area, which would more accurately represent these areas’ treatment needs (Molokai versus Maui, versus Hawaiian Homestead Lands, versus Wai‘anae on the Island of O‘ahu). Moreover, the surveys used to gather the data, even when adjusting for age, class, gender, and other key variables, are timestamped with a specific location, yet may be misinterpreted to erroneously cast a small sample of individuals as representative of the entire Hawaiian population outside of that point in time and location (see also Gfroerer, 2019). Local and ongoing documentation is required to understand treatment needs in terms of the particular substance and its degree of community integration and acceptance (i.e., substance use constituting a perceived problem outside of being simply “unhealthy,” “immoral,” and “illegal”; Jaffe, 1983; Waterston, 1993) and the prevalence of substance use disorders localized at one point in time (Hoffmann, 2020). Current drug use statistics, then, do not shed light on actual rates of DSM-5 substance use disorder among Hawaiians. This renders questionable any statement about the treatment needs of Hawaiians or the cultural competency of service delivery based on this data. Given the paucity of quality data, the effects of (new or old) approaches to substance use and specific drug treatment regimes in Hawai‘i’s publicly funded treatment system are currently unknown (Williams, 2019). The social, political, environmental, economic, health, and educational systems impinging upon behavioral health are no longer under the functional control of the kingdom’s government and continue to operate within colonial contexts in the State of Hawaii. Subsidized by the State, treatment programs and human services agencies form part of the social control infrastructure within State apparatuses and can be viewed as a modern form of colonial domination. Berridge (2013) demonstrates the powerful influence of State-sanctioned policy by historically tracing the impact of government regulation (e.g., legislation against public smoking) on societal culture that in turn affects the perceived legitimacy—norms, attitudes, acceptability—of substance use: a persuasively powerful cultural process of change inexorably felt in the hearts and minds of the general public (p. 5). Top-down administrations of contemporary “systems of care” generally replicate forms of control, containment, regulation, punishment, penalty, and coercion of Indigenous People as a feature of colonial bureaucracies (Blume, 2020; Jankowiak & Bradburd, 2003; McKnight, 2003; Muller, 2020; Saggers & Gray, 1998; Steinberg et al., 2004). Moreover, any program, as an institution of the dominant society linked to private and public agencies and interlocked with federal and State funding schemes, that uses the term culturally integrated usually means that Native Hawaiian practice, is, at best, offered separately on a parallel treatment track and remains largely fragmented within the treatment agency, with limited influence on behavioral health care (Williams, Laenui, et al., 2021). As a certain eventuality of colonization and coloniality, Hawaiian cultural practices are subordinated to the cultural dominance of Western/American approaches and not given full recognition; that is, the language, history, song, music, protocol, story, concepts, beliefs, and healing traditions are largely ignored, excluded, or rendered tokenistic in “systems of care” (see also Pukui et al., 1972, 1979). Conversely, cultural practices may be visibly displayed and touted in treatment programs while processed through top-down bureaucratic control mechanisms and conducted in such a form (culturally flawed practices unsupervised by Hawaiian cultural experts) and fashion (a false and divisive binary of “culture” versus “clinical” that creates structural discord, fostering programmatic disharmony at all levels with a high potential for iatrogenic impact on clients and staff, and a dispirited lack of lōkahi in terms of social and psychological integration of treatment value and therapeutically meaningful participation in program activities) as to institutionally undermine the legitimacy of Native Hawaiian cultural practice as a viable intervention (Williams, 2019; Williams, Laenui, et al., 2021).

Individualism—This element is protected in the legal system, elevated throughout history, and dominant in Western philosophies. Central to this formal characteristic is the idea of singularity: a continual parceling and fragmenting of things, concepts, and people. For instance, although the treatment modalities in most treatment settings may include groups, the treatment is clearly targeted at individual clients (Blume, 2020; Duran, 2019; Linklater, 2014; Muller, 2020). Hence, the dominant treatment models focus on individuals—the individual is allowed but not their children, partners, or family members—and avoiding risk (exposure to people, places, environs, feeling certain emotions, substance use, etc.) rather than on managing risk through engagement and decision making at the familial, community, and nation level (Blume, 2020; Blume et al., 2021). All aspects of care, from treatment plans and goals to specific care regimes, are focused on the individual. Although this perspective is necessary to a large extent given the Americanized “system of care” and its expression of cultural values, expectations, and norms, it is in itself incomplete and certainly does not fit in the narrative arc of a much longer social relationship between Hawaiians and the Islands that precedes the existence of the State of Hawai‘i as part of the unscripted worldviews of Native Hawaiians. The more traditional view of Hawaiians is to perceive health and well-being collectively in relation to the societal contexts of family and community. This interplay between relational pressures and health-related norms impacts both treatment and Hawaiians receiving services. Additionally, from a much broader and more complete historical perspective of the continuing American occupation of Hawai‘i, “living in a colonialistic setting” and its associated intergenerational trauma are experientially and perpetually felt “historical” constructs connected to contemporary metal health symptomatology and substance misuse (Duran & Duran, 1995, p. 8) that nonetheless elude diagnostic and psychometric assessments of the Native Hawaiian psyche (Rezentes, 1996). As a subject of treatment recovery, as well as a material reality to be confronted and engaged as a means of therapy, the fact of colonization in the Hawai‘i Islands and the communities Hawaiians are primarily concentrated in are showcased in Hawai‘i’s colonial television news outlets as areas prominently beset with stereotypical social ills and family calamity (Kauanoe, 2021). The health-related ramifications of Hawaiians residing in a stigmatized zip code (e.g., 96792 is correlated with inequalities in access to power, business capital, education, health, income and wealth) with its diminished prospects of upward mobility as an artifact of colonial domination are dimensions largely absent from conventional behavioral health and drug treatment conceptualizations, procedures, processes, and outcome measures. Prevention and treatment measures can operate with less reliance on professional treatment through direct investment in building up (social and economic) infrastructure and living conditions in Hawaiian communities beset with truncated educational opportunities and reduced resources within economically circumscribed communities. This can, in turn, enhance life prospects that extend to the environmental generation of social settings and networks that are beneficial to regulating conditions and activities associated with substance misuse in neighborhoods, thus preempting police intervention and criminal justice control (Harding, 1998; Klinenberg, 2018).

The contemporary form of mental, behavioral, and addiction treatments is often dominated by experiences and training that emanate from colonial societies and consider their “best practices” as “proven” and normalized to a colonial culture and society (Williams, Rezentes, et al., 2021). Ultimately, this becomes another attempt to impose a set of values and beliefs—a morality—on the Hawaiian person. Kalant and Kalant (1966) note the difficulty in parsing values from facts. Specifically, substance users and non-drug users “may share the basic value that happiness is good, and the wish that most people should be happy. But if they disagree about the facts concerning what sort of behavior makes people happy, then the values they attach to different forms of behavior will also differ” (p. 7). Institutionally established standards for behavior and goals for achievement—i.e., values and attitudinal norms (Leacock, 1971, pp. 11–12)—can inculcate definitions, recovery concepts, health benchmarks, and notions of healing, pathology, and success that can be self-sabotaging and antithetical to personal growth and development, as well as to Hawaiian cultural identity and nationalism. Successful adaptation to the conditions of State-sanctioned incarceration is contingent on self-preservation or a highly selfish survival-oriented morality. For example, State-subsidized drug abuse treatment programs and the State’s criminal justice system work in tandem to coercively compel Hawaiian people into abstinence-oriented lifestyles and regard any substance use—whether for spiritual reasons, communal bonding, cultural revitalization of indigenous psychoactive drug use, or motivated by other intent with therapeutic purpose such as a response to unknowing cultural loss, oppression, historical trauma and generations of forced assimilation (e.g., Coomber & South, 2004; Edwards et al., 1983; Pokhrel & Herzog, 2014; Williams, 2016; Williams, Makini et al., 2021; Williams, Rezentes, et al., 2021; Williams, Davis, et al., 2021)—as problematic social activity that is emblematic of failure, worthy of treatment termination, and warrants a suspension of free will. Kalant and Kalant (1966) underscore the so-called “bad” effect of drug use:

…the traditional view of Europeans and North Americans would be that such an effect is bad because it impairs useful work, diminishes productivity, and lowers the material standard of living of a large number of people who may become charges upon the rest of society. In contrast, those who find that our present society is overly materialistic, excessively competitive, hard-driven, and devoid of tranquility and introspection might well find these drug effects desirable. (pp. 6–7)

Exclusion—This element is often accomplished by the depersonalization of the “other,” the stranger. One patent colonial technique is to refer to others as nonhuman entities—“heathens,” “pagans,” or “savages”—as missionaries did in the early 19th century when they clashed with native ways of being and the traditional religion of Hawai‘i, known commonly as the Kapu or Mana belief system (Merry, 2000).The colonial system elevates academic achievements in specialized fields and accumulated entitlements from academic circles, while contemporary traditional healers of the Hawaiian community—the Kupuna, Kahuna, and Kanaka Makua (identified as people with the maturity of parents)—are erased, degraded, and generally eliminated from the treatment community. Their “credentials” of experience and training in fishing, farming, warfare, hunting, and gathering, and their resolution of interfamily or intergang conflicts within communities are given no credibility in the State’s colonial “systems of care.” The tools of traditional healers such as prayer, ho‘oponopono practices, la‘au lapa‘au (herbal and other traditional medicine, including water treatments), la‘au kahea (treatment using a “call,” such as a chant or prayer, that works on a spiritual level), or other counseling activities conducted by such traditional healers are discredited and therefore not reimbursed. The healers have no regular place to practice their treatment, which is generally performed in informal community settings such as farms (Hoa‘aina o Makaha), fishing training facilities (‘Opelu Project), and ocean vessels (Hokule‘a, Hikianali‘a, etc.). Moreover, agencies buttress their services on individual assumptions, emphasizing the client’s individual psychology at the expense of their relational concerns within their environment, their political positioning, and/or their economic situation. For instance, the prevailing orthodoxy of publicly funded treatment programs and the criminal justice system is the entrenched view on rehabilitating the lifestyles of lower-class individuals by stressing individual responsibility. Thus, the cause of substance misuse for those of lower-class status is cast in “drug subcultures” that are believed to be autonomous and correlated with crime, family breakdown, regressive values, and psychological problems, as opposed to the actuality of associating drug use with upper-class culturally determined corporate capitalistic values (such as parental absenteeism due to the value placed on overwork and career advancement, consumer debt/consumption, hyper-individualistic indulgence of a self-interested American dream inspired lifestyle, the hoarding of material resources, and the reduction of social relations to competitive market exchanges).

Substance misuse for a portion of Hawaiians is the end product of the legacies of forced acculturation and intergenerational trauma due to the American colonization of Hawai‘i negatively reverberating on Hawaiian genealogies of the past, present, and future. This, however, is outside the individualized treatment model, even though is it at the center of Hawaiians’ cultural understanding—due to the—of mental health and well-being, which is rooted in the endemic psychological, cultural, social, environmental, political, and economic losses pervading Hawaiian communities (Rezentes, 1996). The path to “Hawaiianness” is akin to sobriety as, for many Hawaiians, both assimilation and substance (mis)use mask the effects of cultural oppression, loss, trauma, and being overwhelmed and overtaken by haole (foreigners).

Lacking a communalistic focus, treatment modalities create a fundamental cultural mismatch that excludes the material realities of Indigenous Peoples and results in a mode of treatment that casts behavior as a discrete function of the autonomous individual and their beliefs through the paradigms of motivational enhancement and behavioral modification (Blume, 2020; Blume et al., 2021). Further, these treatment modalities are employed in an office-based setting that undermines the communal embeddedness of the individual as a whole being and does not improve community autonomy. Instead, it encompasses the attendant political disenfranchisement, social suffering, and economic marginality that is correlated with lowering life chances and elevated risk for mental illness and drug misuse (Duran, 2019). As such, service delivery for Native Hawaiians compartmentalizes the individual and largely ignores or excludes their familial and communal and national interdependence; a reductionist paradigm of the Hawaiian psyche/psychology (Rezentes, 1996). Paradoxically, the allocation of public tax dollars to “systems of care” excludes Native Hawaiians due to the absence of Hawaiian representation in administration and management. Yet, in a twisted sense of compounded irony, academics, practitioners, State authorities, and program administrators emphasize cultural humility, cultural competence and “diversity training” vis-à-vis the over-inclusion—or rather, stark disproportionality—of Hawaiians as Medicaid-funded social service users, a result of State-sanctioned coercive pressures (OHA, 2014, 2017, 2019). A hallmark of top-down colonial governance is the absence of natives in the management and administration of colonial institutions and agencies (Hochschild, 1999; Saggers & Gray, 1998; Steinberg et al., 2004). In the case of Hawai‘i, while State funding of human services and other treating agencies mostly benefits non-Hawaiian employees representing “systems of care,” the State nonetheless highlights in its own reports the total funds exceedingly “expended for Native Hawaiians” as a hypocritically self-congratulatory testament to its commitment to “cultural sensitivity” toward a “special group” (e.g., see Alcohol and Drug Treatment Services Report issued by the Department of Health’s Alcohol and Drug Abuse Division, 2021; see also Williams, 2019).

Hale Na‘au Pono: Cultivating the Cultural Elements of OLA Against the Forces of DIE

In the 1970s, the State opened a clinic to service the population of approximately 40,000 residents of Wai‘anae. A community elder, Marie Olson, who wanted to gauge the utilization of services, spent a week sitting in the waiting room of the clinic counting the number of clients who came in to receive services; she counted only three during the week. Olson and other community elders petitioned the Hawai‘i State Department of Health to devolve service responsibility to the community. The State took up this opportunity, agreeing to spin off the Wai‘anae “catchment area” to a nonprofit community entity in order to see whether a model could be established for community empowerment in mental health services. With this “go ahead” from the State, the community organized a nonprofit organization, the Wai‘anae Coast Community Mental Health Center, and obtained a 4-year grant to develop a center in the hopes of providing a model for communities to run their own behavioral health care centers. The new organization adopted a name, Hale Na‘au Pono, and over a period of several years recruited personnel and leadership and developed a clear statement of its community and cultural connection to services. It began a private funding campaign for a modern building in the heart of the community and established a central presence through that location. HNP’s community-based board of directors selected a member of the community who had previously been a volunteer board member to steer the organization through the coming years. Several unique approaches and services to the community were rolled out, though HNP still operated within the confines of an Americanized model of behavioral health practice and a colonized system of healthcare delivery. The State, for instance, exempted itself from the requirements that services be accredited by a national accreditation commission. As a result, the financing of these services was thrown into confusion. Indigenous services that did not meet the specifications of the State, such as the cultural or spiritual aspects of an individual’s recovery plan, were not reimbursed, and (cultural) practitioners who did not meet the credentials as set forth by the State were not paid. As HNP proceeded to develop its Wai‘anae style of practice, it had to begin with the basic format of the practice already established by the State system and its regulators/standard-setters (Laenui, 2001a). Upon that established practice, HNP adopted a number of unique principles and processes based in traditions, as part of its effort to imbue an OLA approach to health (Laenui, 2001b). These are listed in the following section. Documented here is the workings of a Community Mental Health Center, Hale Na‘au Pono, and how the theory and the praxis around OLA care models renders problematic, dominant notions of colonial regimes of mental and behavioral health, substance use, drug treatment, and recovery.

The Constitutive Elements of OLA Cultural Care Models

‘Olu‘olu—This is a person who is amiable, agreeable, and who creates harmonious relationships; who displays a high degree of respect and trust when interrelating with others, even competitors; who is able to find contentment with what they have; and who stays within the bounds of their kuleana (territory, property, or responsibility). One way to ensure ‘Olu‘olu in the behavioral health center is to include the voices of service recipients in ways that allow their worldview to positively shape and impact the development of services. This can be partially achieved by gathering data either from feedback-informed treatment or measurement-based practice (Scott & Lewis, 2015) through asking the Native Hawaiians who have experienced treatment to rate the benefits of various components of it (Williams, Laenui, et al., 2021). Such measures do not refer to any subjective “satisfaction,” but aim to discover which components have been useful to recovery. Respondents could also be asked to suggest changes they believe should be made and to mention any instances of their cultural heritage being devalued or feeling demeaned or disrespected by providers. Specific areas where the answers cluster can prove illuminating and serve in identifying which program components are helpful and which are not. Once the salient topics are identified, many of the constructs could be quantified on a Likert scale. If the construct is “real,” it should be measurable and can be grouped and scored. ‘Olu‘olu runs contrary to the hallmark of top-down colonial governance that either outright disregards native voices or appropriates and misconstrues such voices in the interest of maintaining the colonial status quo (Hochschild, 1999; Jankowiak & Bradburd, 2003; Saggers & Gray, 1998; Steinberg et al., 2004). ‘Olu‘olu also entails gathering information grounded in the patients’ needs and preferences to tailor treatment matching, where deemed culturally appropriate by Native Hawaiians in terms of ascribing: procedures (e.g., use of Hawaiian cultural protocols monitored and supervised by cultural experts) processes (e.g., behavioral health interventions meet Hawaiian people where they are at; in their respective communities and families), and outcome measures (e.g., a rise in Hawaiian national consciousness linked to improved mental health or remission of drug misuse). For instance, HNP differentiated itself, in part, from colonial systems of care by emphasizing communalistic (rather than exclusive individualistic) notions of care in perpetuating the indigenous Hawaiian practice of Ho‘oponopono, a native healing practice of reconciliation and forgiveness that is a widely practiced and commonly accepted aspect of cultural heritage within Hawaiian families. Ho‘oponopono is intended to bring the notion of ‘Olu‘olu into the individual by restoring pono (proper balance, repair) in the individual’s communalistic relationship to the secular world and non-secular forces (ancestor spirits, family guardian spirits [aumakua], and God or gods) by cleaning away the hihia, or entanglement, that has caused problems (Laenui, 2000a; Pukui et al., 1979). Ho‘oponopono practice and its underlying mechanisms of action is the most extensively documented Hawaiian healing tradition in the extant literature, but the point here is that practitioners are committed to, as well as deemed credible and honored by Hawaiian communities.

Lokahi—This is a collective effort, with many working toward a common goal that leads to a clearer view of the wider implications of all things. Similarly, positive outcome measures or improvement rates for wellness could include how “systems of care” have impacted the individual’s holistic well-being as well as that of their families and communities. Efforts toward recovery are commonly institutionally controlled and isolated from the relationships to (extended) families and the broader environment/land that surround and support Hawaiians, rather than being community grounded (Rezentes, 1996). Moreover, an individual’s positive treatment outcome would mean an improvement in their overall communal quality of life (Blume, 2020; Blume et al., 2021) and include acknowledging and addressing the consequences of coloniality and the mental health impacts of the continual U.S. occupation of the Hawaiian islands on Native Hawaiian cultural well-being. Following David’s (2011) interpretation, the extent to which Hawaiians are “connected with, comfortable in, and can appropriately function within their heritage culture” varies as enculturation (p. 159). Drawing further on the work of Berry (2003), David (2011) notes “the extent to which an individual does or does not stay connected with their heritage culture or the degree to which an individual connects or does not connect with another culture is called the process of acculturation” (p. 159). Accordingly, the stressors of sociopolitical factors and responses such factors incite in Hawaiian nationalism, sovereignty, independence, and how Hawaiians are forced to change or adapt to the economy, unemployment, discrimination, can psychologically incite acculturative stress (David, 2011, p. 159; Salzman & Laenui, 2014). Here, a person can acculturate in four different ways: “assimilation (high adherence to dominant culture and low adherence to heritage culture), integration (high adherence to both cultures), separation (low adherence to dominant culture and high adherence to heritage culture), and marginalization (low adherence to both cultures)” (David, 2011, p. 160; citing Berry, 2003). As a conceptual framework with communal dimensions, Lōkahi, as understood by HNP (individuals who are communally embedded agents operating in a historical and contemporary sociocultural context), is understanding what form of acculturation alone or in combination contributes better to Hawaiian well-being and mental health and helps Hawaiians work toward their achievements, which likely contributes to the development of a positive ethnic identity associated with psychological well-being (David, 2011; Salzman & Laenui, 2014). For instance, assessment protocols have been found necessary to “learn about the family’s Hawaiian identity (Hawaiians, bi-cultural, non-Hawaiian)” to better understand Hawaiian values, beliefs, and rituals implicated in family conflicts and affecting the degree of cultural responsiveness of service delivery (E Ola Mau, 1985, p. 124).

Aloha—This is a propensity toward the inclusion of other people and different philosophies; a search for the humanity within others and an effort to draw that humanity to the surface of relationships. The all-inclusive Aloha draws into the family all of the surrounding environmental elements, which carry a spirituality that unites the family and environment. From a Hawaiian perspective, recovery means healing native communities and families from the damages caused by colonization and restoring total control of the Hawai‘i Islands to Hawaiians as the authors of their own destiny, alongside restoring proper relationships that are central to the holistic frameworks of sovereignty, political self-determination, independence, and autonomy essential to wellness and recovery (see also Million, 2013). Treatment therefore includes the haumana, or client, and others associated with the client (including their spouse, partner, employer, and children). Together with a recovery coach, cultural informant, or nurse, they can impart a program of recovery that ideally would include cultural features relevant to the haumana’s specific circumstances. For instance, a core area of cultural consideration in HNP’s treatment modality includes focusing on the environment to tap into spiritual elements, furthering its distinction from standard colonial care models entrenched in Eurocentric conceptions of professionalism that are indifferent to the overlap between environment and spirituality. This focus is relevant to addiction and serous mental illness recovery pathways, especially the aspect of balance or harmony (Laenui, 2006). For example, returning to the ocean is a method of washing away tensions and negative spiritual moods, a spiritual cleansing via immersion into the original amniotic fluid (i.e., the Pacific Ocean). In addition to the ocean, the mountains and valleys provide healing for Hawaiians, as do plants. In line with traditional native practice is the belief that natural elements (e.g., plants) carry mana (spiritual energy), which assists in healing by correcting energy imbalances and cultivating a cultural identity (Rezentes, 1996).

Conclusion

The manner in which Hawai‘i’s sovereignty and autonomy was lost to illegal colonization is constitutive in the national history and memory carried by Hawaiians to this day (Blaisdell, 2002; Crabbe, 2007; Kaholokula, 2007; Pokhrel & Herzog, 2014). This reality is still profoundly felt and expressed through strong oral traditions, tightknit communities, and expansive familial networks that span the Hawaiian archipelago (Trask, 1999). This article has underscored the Hawaiian national consciousness in the practice of behavioral health, highlighting a collection of experiences, practices, readings, discussions, and consultations distilled into the training materials that Hale Na‘au Pono developed for its Adult Mental Health division. HNP adopted an OLA cultural care model to be applied in the indigenous context, which centralizes the cultural views of the community and family, emphasizes spirituality and the environment, and adopts general models such as Ho‘oponopono. Specifically, this model follows a basic structure, the Kumu Ola Pono (Wai‘anae Wellness Model), that calls for balance among three realms: the spiritual, the personal/familial, and the environmental (Laenui, 2006). Each is harmonious within itself and between the others. HNP’s system of OLA evolved within the broader constraints of a DIE culture propagated through State and federal laws and regulations preoccupied with risk management, liability, and solving individual problems, with a psychocentric focus on individuated self-reliance and office-based funded interventions defining the discrete and siloed nature of service provisions. At odds with the assumptions underlying the treatment modalities cultivated by the philosophy of OLA, those ontological strands of a DIE culture represent challenges, especially in terms of funding to instigate program failure. These strands, as well as orchestrating pressure and punishment through financial duress, are how the State has controlled the development of programs and attempted to channel the self-determining efforts of HNP into conformity. The observations of other Indigenous scholars with direct practice experience in Canada, America, and Australia (Blume, 2020; Blume et al., 2021; Duran, 2019; Linklater, 2014; Muller, 2020) allude to some of the contaminants of DIE or noxious cultural pollutants generated and present within a colonized “system of care.” The acronym DIE is an easy reminder of the elements of that deep culture stream, which is prevalent in the society’s formal bureaucratic systems, including religious and healthcare practices. It would, of course, be rare to find a purely DIE or OLA perspective in the general community, as these ingrained cultures constantly mix, conflict, and sometimes work together within and between individuals and families, as well as in within certain systems and situations. The presence of these beneficial practices and beliefs justifies a cultural assessment of the entire treatment setting to provide a framework of culturally appropriate ideas on which to build mutual relationships, pursue a healthy interaction with the environment, and reshape attitudes to time, family, justice, sharing and caring, and medicine (Rezentes, 1996). In gleaning the potential differences found in mental health and addiction treatment services informed by OLA, compared to that underpinned by DIE, we hope this article will be of interest to any practitioner operating within a context of colonization and coloniality who is implementing locally developed behavioral health models that offset the cultural infringements of DIE. While the focus has been on the Hawaiian psyche and psychology in relationship to health services, the dimensions of DIE/OLA as a conceptual framework is also a unifying reference point for Indigenous Peoples and other social groups in circumstances for which a treatment milieu conducive to OLA would be useful as they struggle to express their own self-determination through community strength, mental health, and traditions.

Footnotes

Acknowledgment

The authors wish to thank the anonymous reviewers of the journal of Contemporary Drug Problems for their constructive critiques on an earlier draft version of this published manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

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