Alcohol use among American Indian adolescents: The role of culture in pathological drinking

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Pergamon

Soc. Sci. Med. Vol. 42, No. 4, pp. 565-578, 1996

0277-9536(95)00157-3

Copyright © 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

A L C O H O L USE A M O N G A M E R I C A N I N D I A N ADOLESCENTS: THE ROLE OF C U L T U R E IN PATHOLOGICAL DRINKING T H E R E S A D. O ' N E L L and C H R I S T I N A M. M I T C H E L L National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, University North Pavilion, Denver, Colo.. U.S.A. Abstract--Over the last 20 years, the field of substance use among American Indian adolescents has come to be dominated by survey approaches that are unable to answer important questions about how the use of alcohol and drugs is conceptualized and meaningfully integrated in the lives of Indian teens. Without a model of adolescent alcohol use that incorporates culture, the field misapprehends the social and cultural grounding of both normal and pathological drinking, and cannot accurately differentiate between normal and pathological drinking. Traditionally, the field has relied upon either a biological model or a distress model, thus locating pathology in the biochemistry of ethanol ingestion or in psychopathological distress. However, findings from an ethnographic investigation of alcohol use among American Indian adolescents suggest that the criteria for distinguishing pathological drinking lie, instead, in the developmental and gender-specific expectations that derive from cultural values. Specifically, at a Northern Plains site, teen drinking is judged by whether drinking has begun to interfere with developmental tasks relating to the cultural values of courage, modesty, humor, generosity and family honor. We conclude with suggestions for clinicians and researchers that offer the potential to facilitate the incorporation of culture into research and practice in the field of American Indian adolescent alcohol use. Key words--American Indian, adolescence, alcohol, culture

INTRODUCTION In the 1960s and the 1970s, the use of alcohol and drugs among American Indian adolescents emerged as the focus of a number of studies. At the onset, these studies were divided into ethnographic [1-3] and survey-based [4-8] approaches. Two *The general lack of explicit research attention to the issues of cultural and social factors in recent studies leaves scholars in the position of offering speculative or incomplete explanations for observed patterns. For example, when faced with a relatively large difference between Indian and non-Indian high school students in the degree to which alcohol use and peer alcohol associations are correlated (0.28 for Indian students vs 0.58 for non-Indian students), Oetting et al. conclude that the difference was probably related to 'some kind of social or cultural differences,' but are unable to say exactly what [14]. Even works that attend to issues of meaning have failed to conduct the necessary ethnographic groundwork. For example, Binion et al. make a very interesting attempt to identify the reasons that Indian and non-Indian youths use to explain their use of alcohol, marijuana and other drugs [17]. Despite the best intentions of the authors, however, this approach is fundamentally flawed--starting as it does with a list of rationales derived from the researchers' outlooks rather than in the world views of the teens. Low rates of endorsement, especially by Indian marijuana users and users of other drugs, alert us to the possibility that the researchers have not yet uncovered how teens explain their drinking and drug taking. SSM42/4--C

decades later, the field is no longer bifurcated--a trend due not, as one might hope, to the successful integration of the two approaches, but rather to the virtual disappearance of ethnographic works. Today the field is dominated by survey-based and epidemiological studies. While offering more and more robust findings about the high rates of alcohol and drug use among American Indian adolescents, such approaches are unable to answer important questions about how substance use is conceptualized and meaningfully integrated in the lives of Indian teens [9-16].* The contemporary lack of attention to the cultural context of teen drinking has crippled the field. The emphasis on survey-based approaches without a concomitant consideration of the cultural significance and patterning of alcohol use replicates a reductionistic vision of the individual that excludes the social and cultural factors that shape and define any significant social action. Specifically, in the emphasis on quantity/frequency measures of alcohol use, the field casts teens as 'biological beings,' whose behaviors while drinking reflect a putatively natural, biological response to a biochemical substance; conventional patterns of alcohol use and their social significance remain peripheral to the issue. Additionally, with its emphasis on measures of psychological dysfunction and deviance, the field casts teens as 'distressed actors,' 565

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whose patterns of drinking reflect a pan-human 'tension-reducing' response of the individual to stress and distress; peripheral to this model is cultural variation in the definitions of normal and pathological uses of alcohol. The 'distressed actor' model is, of course, related to the 'biological being' model to the extent that the effects of alcohol as temporarily palliative, or tension-reducing, are assumed to be universal. In either model, however, the alternate interpretation of teen drinking as culturally and socially rooted has been precluded through the oversimplification of culture. For the purposes of this paper, culture can be defined--in the words of a leading interpretive anthropologist, Clifford Geertz--as "a framework of beliefs, expressive symbols, and values in terms of

*Similar arguments can be found in the psychological literature. For instance, Bandura's social learning theory holds that the attitudes and modeling behaviors of socializing agents--primarily family and friends--are implicit in cultural norms, and are encoded individually as alcohol-related expectancies [19]. Persuasive demonstrations of expectancies come from experiments with a balanced placebo design, wherein alcohol-related expectancies are far stronger predictors of the behaviors following 'drinking' than the specific pharmacological influences (or lack thereof) of alcohol [20]. tThe similarity of these stages to Wolf's description of the stages of intoxication among Alaska Native men who committed homicide during alcoholic ~blackouts' is striking. Curiously, Wolf finds no room for the cultural structuring of intoxication, and is content to ascribe the pattern solely to biochemistry [23, 24]. ~In a similar vein, Hurt and Brown have documented the degree to which culturally molded visions of gender and age shape the drunken behavior of 'town-dwelling' Yankton Sioux [27]. Albaugh and Albaugh noted a similar phenomenon when they noted the performance tribal values of kindness, generosity, and non-interference in the 'transactional games' of Cheyenne and Arapaho who were drinking alcohol or inhaling various substances [26]. §Outside of Indian Country, the relationship between social role and drinking style has been documented forcefully by several researchers. Gordon, for example, delivers a pithy account of the contrasting roles of alcohol use among Dominican, Guatemalan, and Puerto Rican immigrant men in a small New England town [28]. Among the Dominican men, drinking occurred primarily on Saturday nights, consisted mostly of Scotch, and was suave (smooth), reinforcing an image of el hombre serio, the serious man who is conscientious about work and matters of the future. Among the Guatemalan men, drinking consists of weekend binges, with the drink of choice being beer. For the Guatemalans, "the drunk is glamorized and glamorizes himself as a victim of his sentimental heart or lusty roguishness... " [28] (p. 228). Among the men from Puerto Rico, weekday drinking and frequent mixing of drugs and alcohol was common, with drunkenness being seen as a response to the frequent assaults to one's male dignidad suffered by life as an American immigrant. In an equally rich account, Mars describes two distinct styles of drinking among the longshoremen of a coastal town in Newfoundland, Canada, and analyzes how those distinct styles are associated with two classes of workers and worker relations [29].

which individuals define their world, express their feelings, and make their judgements . . . [it] is the fabric of meaning in terms of which human beings interpret their experience and guide their action" [18] (pp. 144-145). To this, we must add that the fabric of meaning is woven and shaped not simply by values but also by relations of power that privilege certain kinds of interpretations or the voices of certain social actors. To uncover the cultural context of any meaningful social b e h a v i o ~ including teen use of alcohol--requires a careful look at how values and relations of power become institutionalized in culturally-grounded roles that guide social action. Reviewing accounts which explicitly address the role of culture in alcohol use and abuse reveals that neither the 'biological' nor the "distress' models are sufficient explanations for American Indian teen drinking. With regard to the first model, several studies have pointed to the degree to which behavior during drinking is culturally patterned, rather than strictly biologically produced.* For example, Kemnitzer [21] and Medicine [22] each describe conventional stages of Oglala Lakota group drinking--from conviviality, to maudlin sentimentality, to bellicosity and hostility, to 'forgetting'--that are only vaguely related to the a m o u n t of alcohol ingested by the participants.t In fact, Kenmitzer goes so far as to suggest that certain changes in affect are absolutely unrelated to the biochemical properties of alcohol since they occur even before alcohol is ingested--such as when individuals in a group shift into a 'party' mode [21]. Similarly, among the Papago and urban Sioux, respectively, Waddell [8] and Kuttner and Lorincz [25] describe some of the striking continuities between drinking behaviors and culturally valued styles of sober social interactions (most notably generosity among kin and friends, and the display of male bravado).++ These studies reinforce the degree to which the effects of alcohol are culturally and socially shaped, and underscore the fundamental misconception that underlies the 'biological being' image of teen drinkers--that the main effects of alcohol use lie in its biochemical properties. The 'distress' model of drinking seems equally untenable given the degree to which ethnographers have been able to identify a congruence between drinking style and social role; in other words, in ethnographic accounts, drinking habits frequently seem to reveal more about an individual's social location within a culturally defined context than they do about his or her psychological motivations.§ Within Indian Country, Maynard has noted, for example, the association of a 'sipping' style of drinking with 'government workers' on the Pine Ridge Reservation, and the association of a 'binge' style of drinking with unemployed, country-side dwellers [30]. She also notes, however, that individuals frequently change their drinking style to match the drinking situation in which they find themselves, lending even

Culture and American Indian teen drinking more credence to the notion that, far from reflecting psychological distress in their 'choice' of drinking style, individuals drink according to the social norms of the situation.* Similarly, Topper concludes from his investigation of 'traditional' and 'modern' drinking among young Navajo males that most aspects of drinking behavior are determined not by individual motivations but rather by the context within which the drinker finds himself [32].t To push the issue one step further, it is useful to consider the account given by Hill of drinking among young Indian males living in Sioux City, Iowa in the early 1970s [33]. Hill argues that the predominant pattern of flagrant drunkenness, fighting and illegal activity displayed by this group is a reflection of their social role as hell-raising youths, rather than an indication of their being "caught between two worlds," an expression of "alienation," or a sign that they are on their way to a "lifelong pattern of dissolute behavior" [33] (p. 188). According to Hill, most hell-raising youths will, in time, transition into the role of "family-man," a role in which the individual may continue to drink but in ways that differ significantly from hell-raising. In other words, young Indian males in this context drink the way they do, not because of acculturative

*Framed as the 'state-trair issue, the psychological literature discusses similar findings about the importance of situational aspects in determining specific behaviors. See, for example, Mischel [31]. tin a related vein, Curley describes differences in the permanency of drinking groups between adult drinkers and teen drinkers among the Mescalero Apache; while most youths drink with fellow 'gang' members, a group with some longevity, adults are more likely to drink with extemporaneously created drinking groups [4]. ~:This argument in no way denies the importance of investigating the psychological factors that relate to pathological drinking. It does suggest, however, that the largest part of drinking style is located in convention, rather than in individual psychologies. It is tantamount to locating the non-emotive styles of Euroamerican males (or conversely, the emotive styles of Euroamerican females) in cultural conventions of gender rather than in pathological psychological functioning or differential social stresses. Thus, if women talk more about feelings, it does not mean that women are more stressed or unable to cope than men who talk less about their feelings. For an egregious example of this kind of misinterpretation in alcohol studies, despite some awareness of culture, see Stevens who argues that an entire generation of youthful Passamaquoddy drinkers may need to be "written off" [34] (p. 140). §See Heath for an insightful presentation relating cultural shifts in U.S. history to changes in when and how the use of various substances has been perceived as ~problematic' [361. ¶This formulation opens the possibility of pathological non-drinking, an idea that appears in some accounts but which, to our knowledge, has not received systematic attention. IJWithin the context of recent social movements, Humphreys and Rappaport [39] discuss the politics of social problem definition; similar issues pertaining to public health are found in Tesh [40].

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stress or psychological distress, but because they are young Indian males in this context. The parallels with the drinking behaviors of Euroamerican college students are clear. To describe any of these young persons as engaging in predominantly psychologically motivated behavior, or strictly biologically produced behavior, rather than in conventional social-role behavior, would be to fundamentally misconstrue the nature of normal and pathological alcohol use. The image that emerges from the ethnographic account is one in which the greater understanding of drinking behaviors comes from an analysis of cultural norms, rather than in a narrow exploration of individual characteristics:~--which brings us to the issue of how to define pathological drinking cross-culturally. Following the evidence from this review, two issues relating to the role of culture seem particularly relevant to the field. First, normal and pathological must be understood as concepts of value rather than as concepts of "objective" reality [35]. Rather than by biochemical imperatives or knee-jerk responses to stress, the normal and the pathological are framed by cultural definitions of 'the good life.' An individual, and/or his/her family, will perceive pathology, when there is an alteration of the normal, according to value-laden qualities that have been constructed as important in his/her cultural world.§ This observation simply reiterates the point made repeatedly by ethnographers of alcohol use, and put succinctly by Topper, that "[e]very drinker has a culture, and when he is living among his people, he drinks in a manner which conforms to cultural or sometimes subcultural norms. It does not matter if his drinking is considered to be culturally appropriate or deviant, it will still be performed in a manner which is culturally patterned" [37] (p. 78). Until the cultural context of normative drinking and nondrinking has been ethnographically investigated, pathological drinking will remain an unknown quantity.¶ Second, the normal and the pathological must also be understood as political concepts, inextricably linked with relations of power as certain social actors are credited with the authority to define behaviors as problematic. Following Sargent we must be sure to ask at a very basic level: What is 'the problem'? Whose problem is it? And, who benefits from the problem and certain ways of defining it? [38] (p. 186).11 Until this has been done, outside and indigenous researchers alike are at risk for contributing to the hegemonic spread of Euroamerican values and problem definitions into less-powerful communities [41]. The unwarranted pathologization of American Indian adolescents, and their societies more generally, is a potential danger that inheres in the naive application of Euroamerican judgements to American Indian drinking. It is a danger that can only be avoided by the rigorous

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ethnographic investigation of the normal and the pathological within each community. Twenty years ago, Brod noted, in a level-headed review of the extant literature, that "our major insight about Indian alcoholism is that we are unclear about how to consistently differentiate deviant from normative drinkers" [42] (p. 1387). He concludes that, until we know more about Indian drinking and how it is rooted in unique world views, we should avoid the term 'alcoholism.' Brod's injunction still holds true today, in part because the ethnographic emphasis on the normative dimensions of alcohol use remains vague vis-d-vis the phenomenon of pathological drinking in American Indian societies.* As Topper notes, "It is interesting to know that drinking is culturally patterned, but unless these patterns can tell us something significant about the relationship of alcohol use to the rest of a cultural system and unless this information is usable in a medical (or a research or an interventionist) context, then the cultural aspects of the drinker's story comprise little more than interesting ethnographic accounts" [37] (p. 78). In the following pages, we explore alcohol use among American Indian adolescents living in a small town on a Northern Plains reservation. This account of teen drinking is based on three years part-time ethnographic research by the first author. Over that time, the first author has conducted formal in-depth interviews with ten adolescents (five of whom have been reinterviewed at an 18-month interval), has led several group discussions with both teens and adults, has informally questioned teens and adults in a variety of setting, and has been able to observe teen

*See Room for a stimulating argument that anthropologists have tended to 'deflate' the problems associated with alcohol use in other societies [43]. He traces this 'minimizing' tendency to a disciplinary focus on 'social functionalism,' a methodological emphasis on the 'everyday,' the location of most American anthropologists in the 'wet generations' of American history, the professional/political stance of relativism vis-~-vis the moralizing stance of missionaries/colonial administrators, and the neophyte status of most anthropologists as alcohol investigators. tFor readers unaware of this traditional warrior practice among Northern Plains tribes, it is useful to read Hasserick's description of counting coup among the Sioux [45]. He writes, "Courting death became as important a part of warfare as victory, so much so that acts of valor were classifiedin a recognizedsystem of war honors. Men who 'struck' the enemy were said to have 'counted coup,' and whether or not the enemy was killed or wounded, the record was not jeopardized. The fact that the man was courageous enough to 'touch' an opponent and risk death than shoot him from a safer distance showed the caliber of courage which the Sioux pattern prescribed. An individual's position depended in part upon the number of coups he had counted, and those who accumulated a large number were conceded to be men of great renown" [45] (p. 33).

life through participation in community, school and family events. On the basis of this research, we attempt to deliver not only an interesting ethnographic account, but one which also explicitly attends to the ways in which teen drinking is judged locally as normal or pathological. Most notably, drinking among Northern Plains teens, both normal and pathological, emerges as a phenomenon that is best understood, not as it relates to the biochemical properties of ethanol, nor as it relates to a stress response, but as it relates to important aspects of Northern Plains history and culture.

HISTORICALAND CULTURALBACKGROUND One of the largest Indian reservations in the United States, the Northern Plains reservation at which this work was conducted is located in the heart of the Northern Plains culture area and is home to one of the larger bands of Plains American Indians. When the reservation was established in the latter half of the 19th century, the people brought with them an historically and culturally shaped vision of the good life. Some aspects of the Northern Plains vision have permeated mainstream Euroamerican consciousness of Indian life. Indeed, the images of early Northern Plains people as nomadic hunters, warriors and horsemen have become emblematic of early Indian life more generally [44]. While the stereotyping of the histories and cultures of all Indian tribes and peoples in terms of the Northern Plains warrior is problematic, the residents of this reservation are, in fact, true descendants of that way of life. Reservation life in the 1990s reflects that history in important ways. The ancestors of contemporary residents of the reservation were warriors who counted coup,t hunters who pursued the great buffalo, and young men who underwent the ritual self-sacrifice of the Sun Dance. Despite the power and accuracy of these images, however, essential pieces are missing, if we are to appreciate the early Northern Plains vision of the good life. Perhaps most importantly, what is left unspoken in these images of individual male prowess and self-aggrandizement is the larger structure of the extended family, the tiyospaye, within which the actions of the hunter or the horse-stealer derived their significance. Rather than acts of simple self-glorification, the dramatic displays of bravery and fortitude performed by the warrior reflected his disciplined self-sacrifice for the good of his family [45]. Moreover, while the commanding images of the young warrior document the Northern Plains glorification of a specific view of masculinity and youth, the images overlook the recognition and admiration for the complementary roles played by others in holding a family together [46]. Older men, particularly in the grandfather generation, were esteemed for their wisdom and powerful spiritual knowledge. Women, too, has valuable roles to fulfill, as sisters honoring

Culture and American Indian teen drinking their brothers through modesty, as wives bearing and caring for the warriors and maidens of the next generation, and as mothers and grandmothers with teaching and spiritual roles [47]. In other words, the well-known masculine values of courage, fortitude and wisdom, as well as the lesserknown values of generosity and feminine modesty, unfolded as virtues for early Northern Plains people within the context of family life. Ideally, family life was characterized by each member of the family contributing in a socially prescribed fashion to the good of the family, measured primarily in terms of adequate shelter and clothing, plentiful food, health and family honor. Whether counting coup, decorating moccasins with quills, lecturing a young girl on proper in-law terms, or sitting on a council to give advice on ritual ceremony--each family member added to the wellbeing and honor of the family. This was the vision of the good life that the Northern Plains people brought with them when they arrived at their reservation in the late 1800s. It was a vision that would undergo severe strain as their families were confined to the reservation, as the previously vast herds of buffalo were systematically decimated, as horse-raiding and warring came to an end, and as traditional spiritual practices came under attack. The Northern Plains people, who for over two centuries had dominated the Plains, bringing honor to their families, were beaten down. Adolescents at the Northern Plains reservation are the youngest heirs to a rich but tragic history dominated by events displaying the "sordid and shabby" treatment of American Indian people by the U.S. government [48]. That treatment is embodied for many in the Wounded Knee Massacre of 1890, in which close to 200 Sioux men, women and children were surrounded and shot by the U.S. Calvary, and moves forward through history through the assimilationist periods of the late 1800s and the early 1900s, to the neglect of recent decades.* Contemporary reservation life bears the imprint of this record of heavy-handed, politically motivated interventions by the federal government. Nowhere are its results more evident than in the economic realities of reservation living, in which the annual family income is among the lowest in the nation and where the scarcity of employment *For a useful recounting of the Wounded Knee Massacre of 1890 see Brown [49]. tThe "Voices of Indian Teens" project is a five-year research project, funded by the National Institute for Alcohol Abuse and Alcoholism, recently undertaken by the NIMH National Center for American Indian and Alaska Native Mental Health Research. The project entails ten waves of semi-annual, school-based, survey data collection, with a community follow-up of youths not in school. The 'Voices' project is currently located in ten high schools across five sites: South Central (1 school), Northern Plains (2 schools), Northwest (1 multi-tribal school), Southwest/non-Pueblo (1 school), and Southwest/Pueblo (5 schools). See Mitchell et al. for a more thorough discussion of the survey portion of this study [50].

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opportunities has produced wide-spread job insecurity, high rates of unemployment, and extensive dependence on state and federal welfare. As traditional means for achieving the well-being of the family and its honor disappeared, and as emerging opportunities proved either too few or too much at variance with central cultural values, families and communities have been divided into those who opt to try to succeed within the administrative system imposed and supported by the dominant society and those who chose to maintain some distance from that way of life. For the youngest generation, history has set the stage for their awareness of Indian identity, deriving from family values and popular media images of traditional Plains Indian life, and it has set the stage for the emotional valence of Indian identity for individuals and families as their families' choices about how to make a living in an economically insecure environment are linked rhetorically to Indian values. Underlying it all, however, remains the Northern Plains vision of each family member contributing to the family good and its honor, clouded by the ever-present reminder of the insults and threats historically endured by the tribe.

THE SETTING Sitting in his family's car outside the supermarket in the reservation town of Agency, Bobby, a 14-year-old high school freshman, watched with amusement as his father and grandfather teased and berated the old rummy who stood swaying in the cold November wind pleading and crying for a handout. The behavior of his father and grandfather was not unfamiliar; he and his friends would do the same thing when they would pass by the group of town drunks who gathered every morning in the center of town to pool their resources for the day's drinking. On the other hand, Bobby knew that drunks did not always deserve derision. On shopping trips off the reservation, the boy would feel his mother's fear and sadness as she scanned the faces of the groups of drunks who gathered daily in the streets of River Bend, a border town. The boy knew that his mother was searching for her cousin, a Vietnam veteran who was sick and needed to go to the hospital but who drank instead, thereby aggravating the diabetes that could kill him. Bobby himself had had to search the streets for his grandfather, not knowing whether he would find his grandfather passed out or belligerent. Yet he had also known his grandfather to remain sober for months on end, especially around the time of the summer Sun Dances. Agency adolescents encounter alcohol in ways that their mainstream Euroamerican counterparts typically do not. Scenes involving alcohol that would be unfamiliar to many mainstream youth are commonplace to the youths whose families make their homes on the reservation. At a basic level, as for Bobby, exposure to alcohol use is high. Survey results show that this boy's frequent and intimate exposure to alcohol use is not unique in the reservation setting.t At

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this site, only 12.5% of the students surveyed reported that neither of their parents nor another adult who was important to them had had problems with alcohol or drugs. In other words, 7 out of 8 students reported that an adult close to them had had problems with alcohol or drugs, either in the past or currently. Similarly, only 2.3 % of the students reported that none of their friends get drunk. The ubiquity of alcohol in day-to-day life is reflected in the way that the geography of Agency is frequently cast among adolescents in terms relating to alcohol use. Located on the southern edge of the reservation, the town of Agency serves as the seat of the tribal government and headquarters for the Bureau of Indian Affairs (BIA). Agency, with a population of about 5000, also houses the Indian Health Service (IHS) hospital, the tribally run shopping center, a post office, a tribal jail house, several churches, several gas stations and the Agency School. From the perspective of Agency youths, the town is divided into distinct geographical areas, many gaining significance in terms of alcohol use: East Agency, a housing area on the east of town known for its large number of 'party' houses; North Agency, a housing area across from the old hospital; Big Crow, a housing area known for the bootleggers who live there; the grounds of Agency School; and Buddy's, a gas station located in the center of town that provides a meeting place for youths, and a handy location for bootleggers to sell out of the trunks of their cars. Just outside of town, three miles to the south, is River Bend, a small off-reservation town whose bars and liquor stores supply alcohol for the adults in Agency who drink. Circling Agency are several popular teen drinking spots, such as the Dam, or two rodeo grounds known respectively as the 'T' and the 'Satellite.' Further away, are other small reservation towns (possible sources for girlfriends and boyfriends) and several border towns. What the statistics capture, then, is the undeniable presence of drinking and drunkenness among both adults and adolescents living in the Agency community. They evoke the image of shabby drunks staggering by the side of the road in the town of River Bend, of drunk veterans shooting off their guns in the middle of the night, of two ten-year-old cousins sneaking beer from the keg at their parents' party; and of a carload of youths swerving down a country road. What the statistics cited above do not portray, however, is the equally strong presence of non-drinking persons in the Agency community. Some of these people are life-long abstainers; some have stopped drinking

*A number of studies support the strong presence of non-drinkers in Indian communities. See, for example, Levy and Kunitz [51] or May [52].

after a variable period of, oft-times heavy, drinking; some are 'drinkers' who will abstain during important times of social or spiritual responsibility. The prominence of non-drinking people in the community, and in virtually every teenager's family, highlights the conventional association of the avoidance of alcohol with culturally important responsibilities.*

TEEN DRINKING

It is common knowledge among both teens and adults at the reservation that by the time Agency children reach the sixth grade, some have been 'huffing' paint, gas, shoe polish or hair spray for several years, but a fair number do not drink. By the eighth grade, however, few have not participated in some form of drinking, and those who used to 'huff' are now turning away from that particular form of getting high. A good number also use marijuana, or 'weed,' although not as many as are drinking. And while the use of other drugs, such as 'acid' or cocaine, is relatively rare among teenagers, 'speed' is also somewhat popular, especially among boys. While procuring both alcohol and drugs is relatively easy for Agency teens, alcohol is far more popular among most adolescents. Adolescents get alcohol in different ways: taking beer or whiskey from adult relatives who are partying, buying from older students, buying at the bars in River Bend, buying from bootleggers who operate out of their cars, or going directly to a bootlegger's house. Adolescents at the Northern Plains site usually avoid wine, the drink of 'winos,' nor do many drink alcoholic liquids not intended for consumption, such as mouthwash or Lysol, the substances used by 'hopeless alcoholics.' Beer, perhaps the most popular alcoholic beverage, is generally purchased in 64-ounce bottles, known as '8-ball's,' in cases of '40's,' in six-packs of cans or bottles, or in single cans. Some teens express a preference for bottled beer because it 'tastes better," but acknowledge that they generally buy cans because bottles are too expensive. On some occasions, such as for a big party, teens will buy kegs of beer. Kegs, of course, are the most expensive; one respondent indicated a price of $50/keg. A case of ~40s' was $20 and a single can of beer was $3. Agency teens also commonly drink hard liquor. The most frequent form for purchasing liquor is in 'halfers,' half-pint bottles of Blue 100 (peppermint schnapps), Hot or Red 100 (cinnamon schnapps) or whiskey (Canadian Lord Calvert, or CLC, Canadian Windsor and Southern Comfort). Prices for 'halfers' when purchased from bootleggers ranged from $4.50 to $6.00 (compared to about $3.00 a bottle at a liquor store in Denver). For extended drinking, teens

Culture and American Indian teen drinking sometimes purchase liters of hard liquor, such as a liter of Canadian Windsor for around $22.50. While Agency teens have to save for large parties, to pool resources among a group of friends for an evening of drinking, or to occasionally scrounge for money from unsavory acquaintances, for the most part, youths have little difficulty in getting the money needed to purchase alcohol. Most simply ask parents, or other older relatives, for some money. On the other hand, some work to get the money for alcohol, and others sell or pawn personal possessions, such as a Nintendo "Game Boy" or a motorbike. In any event, if a teenager wants to drink, it is not difficult to locate a party at which one can drink for free with relatives or friends. As among adults, adolescent drinking is preeminently social and is part and parcel of 'special occasions,' such as dances, powwows, birthday parties, or even simply 'the weekend,' Adolescent drinking takes place primarily among small groups comprised of relatives and friends of about the same age. Much of the drinking among the younger teens, under 15 years of age, originates among a small group of same-sex friends. After drinking together for a while, younger teens may drive around to different houses looking for parties, where there might be opposite sex friends or acquaintances, or to different drinking sites outside of town. Among older teens, drinking also takes place among small groups of same-sex friends but is just as likely to occur among a small group comprised of one or two romantically involved couples. Importantly, teens described cruising with their friends or going to the various hangouts even when they were not drinking, and had no intention of drinking, suggesting that while the drinking that takes place in these settings is an important piece of a constellation of social behaviors, it is by no means the only important behavior. Despite its conventionality,drinking is perceived by both boys and girls as a potentially risky venture. For boys, there is the risk of physical injury from fighting; for girls, there is the risk of being raped, or damaging one's reputation by having sex while under the influence. For both, there is the risk of landing in jail, getting into trouble with parents, getting kicked out of school, or being sent to treatment. There are also inconveniences, such as getting sick, suffering through hangovers, or trying to avoid getting caught. The risks and inconveniencesof drinking frequently prompt teens to 'quit' drinking. As do adults in this small town, teenagers often describe themselves as 'non-drinkers.' Frequently, what this means, however, is not 'I abstain from alcohol," but rather 'I have decided that I don't want to drink to drunkenness anymore." Often, that decision has been made quite *Readers unfamiliar with rural living may be surprised to learn that it is not uncommon for teenagers, and sometimes even pre-teens, to drive or even to have their 'own" cars.

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recently, and may be rescinded in the near future. Thus, claiming to be a 'non-drinker' may indicate a very short-lived state. Moreover, even when they claim to be 'non-drinkers,' teens may occasionally drink alcohol. For example, in one case, a teenager told me that she had 'quit' in a pact with her sister, who had returned from treatment, but moments later described drinking two cans of beer on a recent night out. 'Non-drinking' and "quitting' are often related to the sense that use has turned into abuse. The subtleties of such terms help us to understand the line between normal and pathological drinking. Just as 'actual' alcohol use may be unrelated to 'non-drinking' (as in the case of the teenager noted above), the quantity and frequency of alcohol use only sometimes enters into the assessment of whether someone has a problem with drinking. More often pathological drinking is marked in terms of interference with or disruption of gender-specific developmental tasks. Building on Havighurst, we can define developmental tasks as age-relevant responsibilities which arise out of culturally-based expectations for developing selves [53]. Thus, in order to understand more precisely the cultural context of adolescent drinking, we must move into an exploration of what responsibilities accrue to teenagers living in Agency in the 1990s. In the next section, we present two short vignettes about the changing responsibilities of adolescents, and then discuss the culturally rooted contours of adolescent development for Northern Plains teens. ADOLESCENTSELVES At 14, Sue Ann was doing well in school, had an out-of-town boyfriend who came to see her on weekends, and had several close girlfriends. Her relations with her parents were fine, even though she was careful to keep from her very strict father news of the few times she'd been out drinking. Despite her successes, all was not well with Sue Ann. Nora, a previously close classmate of Sue Ann's, had started spreading rumors about Sue Ann after the two had argued one night, saying that Sue Ann was a 'whore' and had been coming to school drunk. Then, one Saturday night, after Sue Ann had filled up her car at Buddy's gas station, Nora and two of her friends surrounded Sue Ann's car, pounding on the hood of the car and taunting her, trying to provoke her into a fight.* Sue Ann stayed in her car until the three girls gave up, and then drove home. At home, Sue Ann told her older sister what had happened, expecting her sister to respond with righteous anger at the way Sue Ann had been treated. What Sue Ann did not expect was the response of her father, who had been listening in the background. Without a word to Sue Ann, her father tossed the car keys to her older sister, telling her, "'Take her into town to find that girl." Sue Ann, in contrast to a year or two ago, was now old enough that she could not let slide such an insult to her reputation; it would become her family's shame.

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At 19, Charles had recently married his sweetheart, a 19-year-old woman who was pregnant with his child. In marrying her, Charles also adopted his wife's year-old daughter from a previous relationship, in which the father of the child had never acknowledged his paternity. Despite his legal obligations, however, Charles found it difficult to share his paycheck from his job as a janitor at the BIA building. While he demanded that his wife stay home, he was unwilling to buy diapers for his adopted daughter or gas for his wife to visit her parents. While his family focused on his wife's inability to clean house or cook, her family and others criticized Charles for his 'stinginess' with his money. Indeed, on paydays, it was more likely to find Charles out with his friends than at the store with his wife. A year ago, Charles would not have been faulted for 'stinginess' and might even have been praised for his generosity with his drinking buddies; but now, as a young husband and father, expectations of him seemed to be changing. As Sue Ann and Charles were learning first-hand, adolescence in Agency is a time of profound change. Gone are the indulged days of childhood, idealized as the best time of life by many adult members of this tribe. But the change isn't all bad. With the loss of pampered childhood come various exciting opportunities: to establish a community-wide reputation as an outstanding athlete, student or service man or woman; to develop and expand spiritual awareness and power; to seek out new forms of fun and excitement; to secure paid employment; and to court romantic and sexual relationships. These are opportunities that most children look forward to, when they admire their older cousin's car when he stops by to visit, when they watch as an older brother prepares to pray on the hill, when they observe their young auntie dressing up to meet her boyfriend at the powwow, or when they are the eager and grateful recipients of an older sister's generosity with her paycheck. As Agency children move into their teens years then, they move into a stage of development that is clearly marked with new opportunities and new responsibilities. Within that new world, teens find themselves having to negotiate new relationships of shifting, and sometimes unclear, significance. As pre-teens, primary relationships centered around family members----especially with those of their own generation, siblings and cousins, and those of their parental and grandparental generations. In adolescence, however, young people begin to enter into increasingly consequential relationships with peers, romantic partners, and the wider community. No longer an insignificant matter, the extra-familial relationships of teens come to be marked in the home in the forms of displays of prom pictures or sports trophies. Also, for perhaps the first time in their lives, teens may be counseled by older relatives on whom to associate with and whom to avoid. And some teens, as was Sue Ann, may be told to fight for their reputations. While the family of origin always comes first, these

new extra-and para-familial relationships are of increasing influence in the lives of Agency adolescents. For both young men and young women, the development of a circle of friends with whom one visits, shares resources, and stands together against the members of other groups is very important. These groups often change in composition as individuals shift their alliances from one primary friend to another, and, frequently, the most stable members of a teen's circle of friends are his or her relatives, Regardless of the instability of many groups, however, belonging to a group is essential in providing teens with the social strength to display the courage to negotiate the threats and slander of competing groups and individuals. Without it, both girls and boys are vulnerable to random acts of competition and violence, and girls are thought to be vulnerable to being taken advantage of by boys and being 'talked about' by others. Without it, incidents such as what happened to Sue Ann at the gas station would happen frequently. For both boys and girls, these circles of friends provide the group through which they derive an important part of their identity, and a context within which they negotiate the display of courage or strength. In some ways, however, these groups of friends are less important for young women than for young men, who often speak of the importance of 'brotherhood.' Young women, on the other hand, are frequently more likely to be invested in romantic relationships. While young love is important to many boys, it is of primary concern to girls. The difference in the importance of romantic relationships for boys and girls points to the shared perception that security is realized by having ties to young men--the best way for boys to achieve such security is to belong to a gang of 'brothers,' whereas for girls it is to be the 'girlfriend' of a powerful young man who can garner support from his 'brothers.' The difference in the importance of romantic relationships in adolescence also points, however, to an important facet of girls' lives. Whereas boys and girls are both concerned with the display of courage or strength, girls are equally, if not more, concerned with the display of modesty. Traditionally, modesty was equated with sexual modesty but was also linked with the display of respect (including avoidance) toward various relatives. Today, girls are thought to be modest if they do not 'run around' with different guys, or get themselves into compromising positions while drinking. With few exceptions, young women are held entirely responsible for their reputations, whether good or bad. However, whether in the display of courage by either boys or girls, or in the display of modesty by young women, a teenager's behavior reflects strongly on the family's honor. As the above discussion indicates, Agency adolescents are expected to move into a multiplicity of extra-familial relationships, many of which are dominated by peers. On the other hand, some of the

Culture and American Indian teen drinking new relationships into which teens enter are more diffuse and include taking new responsibilities toward the wider community in a variety of forms. For example, as younger children, Agency youths could move freely about community gatherings, asking for money, disappearing to buy a soda, and hanging out in the parking lot with friends. On the other hand, as adolescents, young men and women are expected to behave more maturely, sitting with the adults, caring for the infants, helping to serve food or do the dishes, or running to the store for a forgotten item. Similarly, as younger children, Agency youths were permitted to be inattentive when important spiritual matters were being enacted or discussed, but, as adolescents, they must attend to the proceedings with the respect that comes with their emerging maturity. For more traditional youths, adolescence also marks the time when they enter into important relationships with powerful spirits, whose strength and guidance will help youths throughout their lifetimes. Adolescence at Agency involves substantial changes from childhood, and while these changes hold promise they can also be difficult to negotiate. While belonging to a peer group offers new sources of identity and sociability, it also necessitates having the material or financial resources to share at the expected level of the group, and, perhaps, having to verbally or physically fight in order to be a worthy member of the group. Similarly, while becoming part of a romantically involved couple also offers important benefits (such as the feeling of being cared for or desired, the exciting possibility of sex, or belonging vicariously to yet another peer group), this too has its potential costs. For girls, the ~talk' of boyfriends can pose the biggest threat to their reputations; for boys, having a girlfriend may put them on the spot for her defense, but may also damage a young man's reputation if he is perceived as lacking the courage to pursue sexual or romantic relationships with other young women, or if he neglects his 'brothers' to be with his girlfriend. Perhaps the most serious prospect that attends adolescence in Agency, however, inheres in the very move into extra-familial relationships--for it is, in fact, peer groups and romantic partners who hold the greatest potential to interfere with a youth's relationships with his or her primary kin group. It is in adolescence that Agency youths must learn to negotiate a culturally rooted and valued style of sociability, in which levels of belonging (to the primary kin group, to a peer group, and to a stable romantic dyad) must be negotiated through acts of alliance and generosity, incidents of competition, and the use of the social lubricant of humor. As younger children, Agency youths learned how to recognize and behave toward their relatives, and they learned how to bond with small groups of same-age siblings, cousins, aunties and uncles. As adults, Agency youths will take what they have learned in adolescence about negotiating different types of relationships and move into more complex and consequential negotiations of

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levels of belonging. Throughout the life-span, however, run themes that paint the Northern Plains vision of the good life: family loyalty and honor, courage, modesty, humor and generosity. How do we understand the use of alcohol among Agency adolescents given what we now know of adolescent lives in this context? Of central importance, when is teen drinking considered pathological? Before turning to a discussion of the locally understood signs of problem drinking, we first present the case of a teenage girl, Toni, whose experiences with alcohol are neither typical nor completely unusual. Hopefully, the specifics of her experiences will help to bridge this description of adolescent lives and the upcoming portrayal of problem drinking in a way that recalls the immediacy of these issues in the day-to-day lives of adolescents and their families in Agency.

TON1

At 15 years of age, Toni seemed unlike many of her classmates. Toni left hanks of her shoulder length hair to straggle across her dark, defiant eyes, while her classmates tended to comb and spray their hair into elaborate, curling masses. Toni's face was unadorned with the careful application of make-up her friends wore, and along with her rumpled clothes, her undecorated face seemed just another sign of a basic uneasiness with her slightly pudgy teenaged body. Unlike the other teenagers who were interviewed, most of whom projected an attitude of wanting to please, Toni seemed inconvenienced throughout most of the interview. At certain points she was evasive and defensive. At the same time, when asked if she wanted to quit, Toni showed a cloying unwillingness to leave that seemed to reflect both her desire to get out of class as well as her need for attention. Toni first drank at the age of 14 with about seven or eight friends at her cousin's 12th birthday party. At the party, she drank several beers but quit when she started staggering. She claimed that she was simply 'buzzed,' and not drunk. She drank again the following weekend. Since that time, for about a year prior to the interview, Toni had been drinking on Friday and/or Saturday nights on a regular basis. She described drinking schnapps, whiskey and beer. The longest she ever spent drinking was for four nights over a school vacation. Toni went to school with a hangover after that weekend, and described skipping school about five times to go drinking. She reported, though, that while her grades had been slipping somewhat, she was still getting As and Bs. At the time of the interview, Toni lived in Agency, but she had also lived in Rapid City, and, for a brief time, in Sioux Falls with her father. Toni preferred Rapid City to any of the other places, primarily because her maternal grandparents, with whom she was very close, had been living there when Toni was. Toni reported that both of her grandparents had since died--a loss Toni felt keenly. Toni lived with her

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mother, an IHS employee, and her step-father, along with her older brother (age 18), and a younger sister. An older sister (age 23) lived in Minneapolis with her boyfriend and their baby. Toni's father lived in Denver with his wife, and her children. Involvement with alcohol/drugs and relationship difficulties were rampant in this family. Toni described her older sister's situation in Minneapolis, noting that both the sister and her husband actively drank and used cocaine, as well as a drug that they put under the tongue or in the eye 'to get high.' The sister had actually just returned to her boyfriend's house after having left for a period of months when he beat her up. Toni also reported that her older brother was an active drinker, and in fact had been a drinking partner for Toni upon a couple of occasions. Toni's main drinking partners included her older brother, two cousins living in Agency (a 16-year-old boy and a 12-year-old girl), and a few of her classmates. Among this small group, evenings of drinking frequently resolved into late night fighting or sexual intimacy. Toni maintained that she had not had sex yet, and when asked about the time she had 'blanked out,' replied that her brother and cousin had been around to protect her from unwanted sex. Upon several occasions, however, Toni had observed her brother and cousin having sex with various girls. About her mom, Toni said, "My mom used to drink a whole bunch and leave us home, and then she quit d r i n k i n g . . . Now if she wants to drink, she's got to ask me and my brother." Toni responded to a question about when she would consent or disagree to her mother's request to go out drinking, saying, "I don't know. [I would say yes if] she's too c r a b b y . . . If they break up [her morn and step-dad], I say 'no,' because if she gets drunk, she's going to go looking for him." According to Toni, her mother and step-father had been together off and on for 12 years, and had married each other "about five times." Toni referred to her step-dad as an alcoholic, a label that she would say to his face when she was arguing with him, a frequent occurrence. She said, "I can't be in the same room with my step-dad without arguing, and if I bring my friends home he tries to show off and impress me, but I just say, 'Why don't you move out of my house, you big old alcoholic,' and he doesn't say anything." She reported that he drank every weekend, and also reported that he regularly did speed, occasionally stealing from her mom to support his use of alcohol and drugs. Toni described starting to have difficulties because of her drinking, including frequent hangovers, her first blackout, and an increased tolerance for alcohol. She also described her mother's threats to send Toni to treatment or to beat her up if Toni kept coming home drunk. With some pride she told about the time her mom drove her to jail because she came home drunk, but how she foiled her mother's plan by locking herself in the car. Despite these difficulties, Toni remarked that she did not want to quit drinking, and insisted

several times throughout the interview that she could quit drinking anytime she wanted. CASE DISCUSSION Contemporary patterns of alcohol use among Agency teens reveal the undeniable reality of teen drinking. How are we to understand these patterns? Is all teen drinking pathological, a reflection of deviance or distress? Since teen drinking, and even drunkenness, is far from uncommon, it seems untenable to label teen drinking p e r s e as pathological. Neither can we realistically decide, however, that there is no pathological drinking among Agency teens. However, if not all teen drinking is pathological, where are we to locate the line between normal and problem teen drinking? Using the most immediate example, is Toni's drinking pathological or not? Many aspects of Toni's experiences are part and parcel of adolescent alcohol use at Agency. Within her story, we hear themes about the social context of Agency teen alcohol use: easy access to alcohol; the popularity of beer and 'halfers'; the prevalence and visibility of adult drinking; the notion of stages of intoxication, starting with 'buzzing,' to getting 'drunk,' to 'blanking out'; and, finally, the important association of drinking with the competition/alliance behaviors of fighting and sex. On the other hand, Toni's experiences are quite different in some ways from what most of her peers describe. Most Agency teens depict alcohol use that draws its meaning primarily through reference to its role in negotiating peer relations: drinking a few beers at the Dam with a few friends on Saturday night, or drinking several glasses of keg beer and a slug of schnapps at the going-away party of a friend. Boys may talk about chugging whiskey with their friends before a powwow, and then walking the fine line between letting other teens know that they have been drinking, and showing too many signs of not being able to 'handle' it. Girls may talk about sipping a beer when they are out cruising around with a boyfriend or girlfriend. In contrast, Toni's stories of drinking center around family relationships, and her use of alcohol seemed to serve primarily as a way to negotiate, indeed manipulate, her own dependency needs within a set of very difficult, painful family relationships. She described drinking to forget her grandfather's death, drinking because she is arguing with her step-dad, drinking because she is mad at her room. When she was drinking, she observed male relatives having sex, and frequently involved them in physical and verbal fights with her classmates, or their acquaintances. Even when she was not drinking, her use of alcohol extended into different realms of her life--as it strained her relationship with her mother, and began to have an observable effect on her school work. In each of these instances, whether in observing the sexual behavior of her brother, in refusing to get out of the car when her

Culture and American Indian teen drinking mother took her to jail, or in taunting her step-father, alcohol played into and exaggerated intensely conflicted familial relationships, already deformed by alcohol abuse. For these reasons, Toni's case cannot be generalized as somehow typical of adolescent drinking at Agency, but would Toni's drinking be judged pathological by her peers? Probably it would be, at least to some degree. Adolescents frequently referred to problem drinking in two ways: dramatic negative consequences, like repeated conflicts with the law or car accidents, or negative changes in affect, that is, being crabby, mean, or 'miz' (miserable) unless alcohol is available. While Toni's drinking fails to reach these explicit criteria, other aspects of her drinking would be judged negatively by her peers: most notably, the frequency with which she fought with her 'friends,' or encouraged her relatives to fight on her behalf, while drinking; the betrayal of the rules of modesty in her relationships with her brother and male cousin; the degree to which she fought with her mother and step-father at home; and the fact that she had come to school 'hanging over.' On the other hand, Toni's drinking probably would not be judged as terribly out of line, either. By local norms, she had not started to drink at a very young age, nor did she drink wine or combine alcohol with other drugs. She drank with her peers, not with adults, and she never drank alone, or even without a 'chaperon' to guard her reputation. She had not ended up in trouble with the law or school officials. In other words, although Toni was toeing the line with her drinking, she had not crossed over into frankly deviant behavior and, in fact, was doing fairly well in many important domains, such as in her school work, avoiding publicly shameful displays, and maintaining her friendships. In order to ascertain the pathological nature of Toni's drinking, one might focus on the age at which Toni first drank, the ease with which she procured alcohol, the fact that she frequently drank 'hard' liquor, and that she drank regularly on the weekends. In contrast, local norms suggest that pathological use lies not in the quantity or frequency of alcohol use, but rather in the degree to which drinking interferes with

*For those interested in the longitudinal aspects of this case, eighteen months after her first interview, Toni had moved out of her mother's house to attend an out-of-state boarding school. There, and during visits home, Toni's drinking more closely fit 'normal' peer-related drinking and had lost much of its familial flavor, the aspect of her drinking which seemed so pathological in the present account. Toni's ability to step off a path that seemed headed for nothing but trouble, at least for the time being, reinforces the findings of Kunitz and Levy who, after 25 years of studying the drinking careers of Navajos, have concluded that several patterns of drinking exist in that American Indian society, but none is necessarily related to a "catastrophic outcome" [54] (p. 11).

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important tasks facing Agency adolescents: maintaining strong and respectful ties with family members and peers, and avoiding potentially shameful incidents for her family in the outside community, such as going to school with a hangover.* CONCLUSION

It is commonly known among clinicians, researchers, prevention workers and lay persons, alike, that different cultural groups define normal alcohol use differently: in Italy, wine is a beverage to be drunk daily with meals: in Germany, beer is preferred for the same function; and among some groups of Mexican peasants, alcoholic beverages are reserved for special occasions only. So it is not too much of a stretch for most people to recognize that certain types of alcoholic beverages, or even alcoholic drinks more generally, carry cultural meanings that affect what, how and when members of distinct cultural groups imbibe. In other words, there is a wide-spread acceptance of the cultural relativity of 'normal' drinking. This relativity vanishes, however, when we get to the realm of pathological drinking, in part, because of the culturally derived strength of biological and psychological explanations within Euroamerican thought and practice. Within this view, pathology is thought to inhere in the alteration or disruption of the universal processes of biological or psychological functioning. As we saw in the opening discussion of the 'biological being' and the "distressed actor' models underlying survey approaches, pathology is thus conceived as universally recognizable. What differs among social groups are the historical and social processes that produce disruption, but the contours of pathology itself do not differ. The preceding pages outline a different approach, in which the nature of pathological drinking among American Indian adolescents living in the reservation town of Agency is shown as deeply embedded within the cultural and social context of contemporary Northern Plains reservation life. Specifically, teen drinking is constructed locally as problematic vis-&vis the cultural values of courage, modesty, humor, generosity and family honor. Moreover, the specific acts which serve as evidence for an assessment of pathological drinking relate to the gender-specific developmental tasks facing adolescents. These tasks may be seen as the institutionalization of cultural visions of the good life in very concrete form. Finally, those tasks are seen to unfold within an historically produced social and economic context which reflects the outcome of countless, power-laden interactions between the Northern Plains people and the dominant society in its myriad forms. Too often, cross-cultural work that might illuminate the cultural context of alcohol use among American Indian adolescents has focused simply on normative drinking, has dealt exclusively with adults, or has been limited to men. More importantly, however, through-

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out this corpus, the presumed biological and/or psychological bases of pathological drinking has remained implicit and unexamined. What we have learned in our work, by opening up our investigation of teen drinking to a cultural analysis, is that pathological drinking is not necessarily defined primarily by biological or psychological processes. Instead, pathological drinking is defined in terms of drinking at the wrong time, drinking the wrong beverage, drinking with the wrong people, doing the wrong things while drinking, or drinking for the wrong reason--and, in each case, ~wrong' is constituted within a cultural value-system that defines it according to developmental and gender-specific parameters. Normal and pathological drinking are both culturally patterned. We think that the implications are clear for different types of work that involve the attempt to understand American Indian teen drinking. For clinicians and prevention workers, we cannot overemphasize the need to place a given patient's (or client's) presentation within the context of his or her cultural and social world. To not do so, in cases where a clinician has little knowledge about the patient's cultural heritage, puts the clinician at risk not only for misinterpreting the significance of a given 'sign,' but, perhaps more importantly, it restrains the ability of the clinician to establish rapport with the patient and to effectively motivate the patient toward healthy change. To many clinicians and health care workers, the task of 'contextualizing' a patient's presentation may seem either an overwhelming investigative task, or one simply of 'empathy.' It is neither and both. One approach that we recommend is to use the Complementary Cultural Formulation developed for the DSM-IV as an outline to elicit the cultural identity of the patient, the cultural explanations for the individual's experiences, and cultural factors relating to the psychosocial environment and levels of functioning [55]. While clinicians will, no doubt, find that there are areas for which there is insufficient information to make a judgement, this outline moves the clinician closer to the patient's world in ways that hold the potential to enhance the therapeutic relationship. For survey researchers, we counsel a similar set of cautions. Care must be exercised at the start of the research in the very selection of constructs. The selection of constructs must, of course, be guided by the accumulated knowledge of the researcher's field--whether social psychology, epidemiology, services utilization, or something else. At the same time, however, survey researchers must ascertain the *Functions that this type of committee can fruitfully perform are many and include: an introductory consultation around the locally perceived relevance of the research topic and specific constructs; a systematic evaluation of the comprehensibility, relevance and appropriateness of the instrument; an assessment of the feasibility of the research procedure; and a discussion of the significance of preliminary findings.

relevance of their constructs for the populations to be surveyed. Moreover, researchers must search for constructs which may have local relevance but which may have been overlooked in the literature. Likewise, constructs must be operationalized in a language that makes sense within the cultural and social context of the survey respondents lives. Finally, in the interpretation of findings, survey researchers must be vigilant in re-uniting documented relationships (or non-relationships) with the day-to-day lives of those surveyed. Ideally, all survey research involving the transportation of Euroamerican beliefs into American Indian communities should begin with an ethnographic investigation focused on the research issues. At the very minimum, we strongly encourage survey researchers to incorporate into each stage of the research a Community Advisory Committee--a group comprised of local people with intimate and extensive knowledge about the issues under investigation.* In this way, survey researchers can increase both the validity of their findings and the applicability of their efforts. For ethnographers, whose job it is to investigate the role of cultural and social factors affecting experience, our recommendations are targeted at a slightly different level. In order to advance our understanding of American Indian teen drinking, ethnographers must continue to focus explicitly on the use of alcohol--documenting the characteristics of the drinking environment (the who, what, how, why and when of alcohol use) and analyzing the role of normative drinking within the larger sociocultural system. However, we want to stress that attention must also be given to the specific contours of problematic or pathological drinking. Specifically, we want to advance cultural investigations that attend not only to the ways that drinking is explicitly spoken about as deviant or pathological, but also to the implicit values that guide those judgements in natural settings. Additionally, such cultural investigations should be guided by an awareness of the continuities and discontinuities in alcohol use, and in the assessment of pathology, that are shaped by cultural visions of gender and developmental differences. Explicit attention to the role of culture in defining pathology, with a focus on gender and development, will not only advance anthropological understandings of culture and the individual, but will also enhance the relevance of cultural investigations for clinicians, prevention workers and researchers. Together, these recommendations push forward the pointed and systematic evaluation of how and when alcohol use becomes defined as 'a problem' within specific social contexts. Moreover, each set of suggestions offers a method that allows local voices to be heard in ways that reduce the risk of misplaced pathologization or, of equal peril, failing to apprehend where pathology truly exists. In each case, we advocate attending to the sociocultural processes of problem definition with an awareness of the political

Culture and American Indian teen drinking implications, a n d the health consequences, for peoples whose voices have systematically been silenced. It is time to i n c o r p o r a t e local values into the definition of the playing field, for the b e t t e r m e n t of scientific u n d e r s t a n d i n g and practical intervention. Acknowledgements--The preparation of this manuscript, and the research upon which it is based, was supported by NIAAA Grant No. R01-AA08474 and by NIMH Grant MH42473. The authors would like to thank our colleagues at the National Center for American Indian and Alaska Native Mental Health Research, Department of Psychiatry, University of Colorado Health Sciences Center, Denver, Colorado. We would especially like to acknowledge Jan Beals, Paul Dauphinais, Ellen Keane, Monica Jones, Spero Manson and Roy Red Shirt for helpful comments on various drafts of this paper. Jennifer Truel was instrumental in locating bibliographic materials. Our discussion of the various case materials was informed, in part, by probing clinical questions posed by William Sack.

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