The Medicine of Culture: A Social Epidemiological Approach to Treating Substance Use Disorder in Native American Adolescents

Substance use disorder (SUD) among Native American adolescents remains one of the most persistent and inequitable public health challenges in the United States. Despite a growing recognition of the role of culture in healing, few studies have systematically examined how enculturation functions as a determinant of treatment success, particularly within residential settings. Guided by the Framework of Historical Oppression, Resilience, and Transcendence (FHORT) and the Social Ecological Model (SEM), this explanatory sequential mixed methods study investigated how enculturation and related social ecological factors predicted recovery among Native American youth receiving care for SUD at a federally operated treatment center. Quantitative analyses were conducted with retrospective cohort data from 120 adolescents to model relationships between enculturation and treatment outcomes, which comprise graduation from the program and reliable change in psychological distress levels. Enculturation emerged as a significant predictor of treatment success, associated with higher treatment retention and engagement. Qualitative analysis of narrative data expanded these findings by revealing that healing unfolded through moral differentiation, restorative order, and spiritual integration, all of which helped youth reestablish belonging and meaning within cultural and relational worlds. Integrating these results framed enculturation as a measurable, protective, and remedial process central to behavioral health equity, thus informing future initiatives to strengthen culturally grounded systems of care for Native American youth.