Overview
Tribal Nations maintain sovereignty status and practice the policy of tribal self-determination, government-to-government relationships, and tribal consultation. The definition of “reservation ” has significance in the evolution of disability legislation because it is linked to legislative advocacy. It is important to note that the term American Indians did not appear in the text of the Rehabilitation Act of 1973 , and in 1975 there were no provisions for culturally relevant services for AIANs in the Rehabilitation Act. It was not until the 1978 Amendments to the Act that the term American Indians was included. By 2014, the term American Indians appeared more than 27 times in the Rehabilitation Act.“Reservation” means Federal or State Indian reservations; public domain allotments; former Indian reservations in Oklahoma; land held by incorporated Native groups, regional corporations, and village corporations under the provisions of the Alaska Native Claims Settlement Act; and defined areas of land recognized by a State or Federal Government where there is a concentration of tribal members and on which the tribal government is providing structured activities and services. (Office of the Federal Register, 2015)
Terminology
Difference – used as the interpretation of disability |
Elder – in the AIAN community denotes a position of leadership, based on experience, spirituality, and community service, rather than on chronological age. (Note: older AIANs are frequently referred to as elders) |
First people – refers to indigenous people of the land |
Indian country – refers to all reservation lands, dependent Indian communities, and all Indian allotments within the borders of the United States. (Note: AIANs in urban areas who maintain strong ties to ancestral tribes and lands, Indian country is also considered a “state of mind”). Because AIANs were not confined to reservations before contact with Europeans, many AINAs consider the entire United States to be Indian country and continue to hold sacred many sites that are not on reservations or tribal lands (e.g., the Black Hills of South Dakota) |
Native – a collective term to describe the descendants of the original peoples of North America |
Tribal members – belonging to a federally recognized American Indian or Alaska Native tribes |
The American Community Survey (ACS) defines a disability as “a long-lasting physical, mental, or emotional condition” that “can make it difficult for a person to do activities such as walking…or to work at a job or business.” Application of this definition means that approximately 23.8 percent of AIANs have a disability (Smith-Kaprosy et al., 2012). It is noted that many Native languages do not have words that translate words such as “disability,” “handicapped,” or “crippled” (Locust, 1986, p. 14). However, from an anthropological perspective, terms for disability and other related concepts and medical terms do exist in certain tribes (see Ablon, Rosenthal & Miller, 1967; Werner, 1965). It is important to remember that the term disability is culturally laden and may intersect in quite different ways both in a comparison of Anglo to Indian and in comparison among different AIAN tribes and peoples (Schacht, 2001).
Traditional Cultural Values and Strengths
The diagnosis and label of disability applied by non-AIANs may be rejected or considered as irrelevant from the standpoint of AIANs. Disabilities are viewed more as possible variations of the human condition in which a person may need assistance from others. The need for assistance does not equate to a handicap that leads to marginalization or disempowerment. Moreover, the type of assistance needed and how it is given also differs from non-AIANs conceptions of removing barriers (Pengra & Godfrey, 2001).The concept of disability in some AIAN communities may focus on whether the individual is living in harmony or whether the individual is able to fill his/her role in family and community rather than an individual’s impairment. Although the term ‘disability’ is now more commonly used in AIAN communities, its meaning may differ from community to community. (p. 25)
Moving beyond the expansive heterogeneity of AIANs, a set of cultural values encompasses their ways of thinking and ways of doing (McMaster & Trafzer, 2004). For traditional Native people, the essence of who they are and how they experience life is grounded in a unique relationship between themselves and the tribe. That is, AIANs are social, emotional, historical, and political extensions of their tribal nation (Atkinson, 2004). Today, many AIANs are rediscovering traditional Indian values and implementing them to revitalize their communities. In the following section, similar to other counseling literature (e.g., Garrett & Portman, 2011; Sue & Sue, 2013), the author makes certain generalizations regarding AIANs’ values.
Cultural Values
Traditional cultural values
Sharing – honor and respect are gained by sharing and giving. Keep only enough to satisfy present needs. Possessions are a means for helping others, whereas ownership relates to current possession. Typically, excess goods are acquired to give away during ceremonies |
Cooperation/group harmony – work to prevent discord and disharmony and believe that the group and family take precedence over the individual |
Living in the present – greater emphasis on the here and now than on the future. Focus on the future is unimportant |
Time is relative – be flexible; enjoy the present. Time is always with us. Nonlinear, relative to the activity at hand. The past and future are appreciated, but it is important to be than to become. Time is considered fluid rather than something to be controlled or managed |
Spirituality – the spirit, mind, and body are all interconnected. Illness involves disharmony between elements. Seek harmony with nature for health. Spirituality permeates all areas of AIANs’ lives. Spirituality is considered a part of the person and their relationship to all that surrounds them, not a religion |
Noninterference – do not interfere with others and observe rather than react impulsively. Try to control self, not others |
Speech – speak in a soft, slow, deliberate manner, stressing the emotions more than the content. Speech is usually a secondary expression to behavior |
Nonverbal communication – learning occurs by listening rather than talking; delayed auditory response. Silence is especially values, and most AIANs are comfortable with silence. Direct eye contact with an elder is seen as a sign of disrespect |
Patience – everything has its place. It is simply a matter of time before a person recognizes where and how things fit together. Everything offers a valuable lesson |
Work – unlike the Puritan work ethic, AIANs understand the need for work, but it is interwoven with spirituality, balance, and harmonious lifestyles |
Certain communication patters of AIANs that contrast those of Euro-Americans may affect interpretation of behavior of AIANs and perceptions of counselors and service providers. For example, AIANs typically avoid eye contact as a sign of respect, whereas Euro-Americans believe that direct eye contact indicates that you are listening and shows honesty and sincerity. Other nonverbal communication patterns of AIANs include minimal body movements, not touching except to shake hands, physical distance, feelings expressed through behavior rather than speech, and controlled emotional expressiveness, except for humor (Atkinson, 2004). Many of these communication patterns can become barriers to service usage and delivery (as discussed later in this chapter).
Family
AIAN family systems are complex and frequently misunderstood by human service professionals. The AIAN family structure varies from matriarchal to patriarchal. Unlike the nuclear family structure (and extended or step family structure) to which most human service providers are accustomed, for most tribes, the extended family is the basic unit, and children are often partially raised relatives (e.g., aunts, uncles, grandparents) who live in separate households (Sue & Sue, 2013). Multigenerational households are very common in a collectivist culture of AIANs. “The feature of lateral extension into multiple households is accompanied by an additional bonding feature of incorporation by which significant non-kin become family” (Red Horse, n.d.). In addition, it is common practice in the Indian way to claim another person as a relative, thereby making him or her a real family member. The belief is that family is a matter of blood and of spirit (Atkinson, 2004). In rural or reservation communities, family structural patterns vary with geographic and tribal circumstances, and structural complexity is most readily understood in remote areas of tribal homogeneity. In remote areas family structure assumes a village-type configuration with several households in close geographic proximity (Red Horse).
Spirituality
Many AIANs do not regard their spiritual beliefs and practices as a religion in the way in which Christians do. The essence of AIAN spirituality is about feelings and connection and forms an integral part of their very being. Spirituality centers on the interconnectedness of the spirit, mind, and body and a balance between these elements to maintain wellness. “The determination of ‘normalcy ’ in health or wellness is dependent on whether or not the individual is in balance with all his or her relations” (Lovern, 2008, p. 5). Lack of wellness is attributed to disharmony in mind, body, and spirit. Disharmony can shift the relation of energies and allows for the occurrence of illness or unwellness. AIAN spiritual and traditional belief is that each individual is responsible for his or her own wellness by keeping him or herself attuned to self, relations, environment, and universe (Locust, 1988; Lovern, 2008). Healing is considered sacred work and in many AIAN traditions cannot be effective without considering the spiritual aspect of the individual. For many contemporary AIANs, it is common practice to use both “white man’s medicine” to treat “white man’s diseases ” such as diabetes and cancer and use Indian medicine to treat Indian problems such as pain or sickness of the spirit (e.g., mental illness, alcoholism). The reader should note that spiritual beliefs of AIANs are determined by several factors including level of acculturation, geographic region, family structure, religious influences, and tribally specific traditions (Atkinson, 2004; see Garrett and Portman, 2011 for additional information).
Old (Elder) AIANs
Old AIANs are distinguished from elders in that old refers to chronological age; however, old AIANs may also be elders. Respect for the old is a traditional cultural value and strength of AIANs. Old AIANs are the “Keepers of the Wisdom” and are highly respected because of their lifetime’s worth of wisdom and experience (Atkinson, 2004). Old AIANs function in the role of parent, teacher, community leader, and spiritual guide. Old AIANs are expected to pass down their knowledge to younger members of the family. A special kind of relationship based on mutual respect and caring takes place between old AIAN and AIAN children as each child moves through the life cycle from “being cared for” to “caring for” (Atkinson, 2004). Old AIANs are storytellers; the bridge between the past and present; libraries of Indian knowledge, history, and tradition; and role models about the tribe’s culture and traditional ways of life (Clark & Sherman, 2011).
Resiliency
Seven themes of the rainbow
Ethos and values – give individuals their sense of belonging to a culture with similar belief systems and practices that guide behavior. For example, respect for others is a paramount value |
Religion and spirituality – was paramount in forming AIAN ideas about resilience. Religion is part of the total circle of life and consistent with their relational worldview. Religious beliefs aid them in difficult times |
Language – seen as critical for passing culture, values, and beliefs to children by parents and elders. An understanding of traditional tribal language is important to convey the meaning of stories |
Extended family – is the nexus of resilience to express itself. The family, clan relationships, extended family, and other relatives play an important role in how they cope with adversity, stress, and crisis |
Responses from the culture – cultural-based practices and tribal programs support members and families to bring out their strengths and to cope with various problems. For example, drumming, sweat lodges, talking circles, dancing, and medicine man |
Sense of humor – the ability to not take life so seriously and an internal mechanism to help us put things into perspective, cope with difficulties , and bring grace into the world |
Moving forward to the seventh generation – is inferred from the Great Law of the Iroquois, which in practice means the AIANs must consider the impact of their decisions on the next seven generations |
Native Model of Difference
The Native model of difference (discourse on disability) is presented to assist the reader to better understand AINAs’ view of disability. First and foremost, in light of AIAN worldview, little attention is given to an individual’s “disability” or difference. Instead, a person’s sameness within the community is what defines the individual (Locust, 1986; Lovern, 2008). That is, a person with a physical, mental, or cognitive disability may be identified as having a difference, but the individual is not classified as “other” based on a disability. AIANs do not see those with disability through the lens of the deficit model. The disability/difference is considered to be one part of the individual’s existence, not his or her identity. The value of the individual is not lessened because of the difference. The idea of wholeness is repeated constantly throughout AIAN culture and their understanding of disability, which optimizes the individual’s humanity. In addition, even if the individual engaged in behavior that might have resulted in a disability, it is not associated with a moral failing or character weakness (e.g., addiction) in the individual (Lovern, 2008). The reader is reminded that the Native model of difference, like any other perspective, is influenced by rate of acculturation and the extent to which the AIAN retains customs, traditions, and language.
Tribal Government and Rehabilitation Services
As with the purpose of all VR services, the emphasis is on individualized, appropriate, and relevant service that will maximize the strengths, abilities, concerns, and choice of the individual.To assist tribal governments to develop or to increase the capacity to provide a program of vocational rehabilitation (VR) services, in a culturally relevant manner, to American Indians with disabilities residing on or near Federal or state reservations. The program’s goal is to enable these individuals, consistent with their individual strengths, resources, priorities, concerns, abilities, capabilities, and informed choice, to prepare for and engage in gainful employment. Program services are provided under an individualized plan for employment and may include native healing services. (US Department of Education, 2016)
Clay, Seekins, and Castillo (2010) assert “disability infrastructure is built upon the existing resources of any community and then extends them for people with disabilities” (p. 143). Regardless of whether urban, rural, or tribal lands, disability infrastructure includes the same categories of services. The challenge for tribal lands is that the quality and access to services is less than adequate. In addition, disability infrastructure in tribal lands and reservations is linked to the economic vitality of the community, which includes natural, physical, financial, human, and social capital (Clay et al.). AIAN communities vary in the degree to which they possess more or fewer of these resources. Because AIAN tribes are not historically and culturally compatible, no one solution can increase opportunities or outcomes for tribal members with disabilities (Clay et al.).
According to Dwyer, Fowler, Seekins, Locust, and Clay (2000), “introducing the concepts of disability and individual legal protections presents challenges that tribal members and leaders must face in order to mutually understand disability within the context of their culture, government, and intratribal relationships” (p. 201). Because tribal governments are likely to resist externally imposed solutions, Dwyer et al. utilized the Tribal Disability Actualization Process ( TDAP) , which is grounded in theories of participatory action research (Whyte, 1991), to include tribal authorities and leaders across five reservations to develop and implement policy recommendations for tribal members with disabilities. The results of the study provided evidence of the effectiveness of a self-directed approach for developing tribal disability legislation, policies, and programs that are consistent with the Americans with Disabilities (ADA). Dwyer et al. suggest that the TDAP was effective for several reasons. First, it allowed tribal governments to utilize the experience, knowledge, judgment, and wisdom of tribal members to create local solutions that are culturally appropriate and respectful of tribal sovereignty. Second, TDAP allows tribal members to shape their own destinies in ways consistent with their individual cultures, traditions, and beliefs. Finally, it offers a mechanism for the cultural translation and reinvention of ideas. Dwyer et al. consider the TDAP “is a truly rural approach to community development that may have universal application” (p. 212).
Rate of Disability
Overall, statistics are alarming on the health status of AIANs. AIANs experience the highest rate of disability of any minority group in the United States and the lowest opportunity for access to culturally sensitive programs and services of all races (National Council on Disability, 2003a, 2003b; RCT Rural, n.d.; Smith-Kaprosy et al., 2012). According to the 2012 US Census, 16–18% of AIANs have a disability, and more than 25% of those who need care are age 64 or younger. It is estimated that among working age (16–64), the disability rate for AIANs is 27%, as opposed to 18% for the general population, and among those age 65 and older, the disability rate is 57.6%, as opposed to 41% (Clay & Greymorning, 2006). Although AIANs have every type of disability that is found in the general population, there are disabilities that occur more frequently among AIANs.
Disabilities most common in AIAN populations
Overall | Elderly |
|---|---|
Alcoholism/drug dependence | Arthritis |
Arthralgia | Congestive heart failure |
Blindness | Stroke |
Diabetes complications | Asthma |
Deafness/hard of hearing | Prostate cancer |
Emotional/mental health disorders | High blood pressure |
Learning disabilities | Diabetes |
Orthopedic conditions | Other cancers |
Spinal cord injury |
The discussion of disability in this chapter is primarily focused on adults; however, AIAN children with disabilities represent a growing number. In the school year 2011–2012, the percentage of children and youth served under Individuals with Disabilities Education Act (IDEA ) was highest for AIANs at 16%. Among those that received services, the 9% of AIANs who received services for developmental delay under IDEA were higher than the 6% of children overall (National Center for Education Statistics, 2015). AIAN children have the highest prevalence of special healthcare needs at 16.6% compared to 14.2% of non-Hispanic white children. AIAN children are slightly overrepresented in the special education population in relation to their percentage of the population, and the majority are educated in the public school system Cohen et al., 2012). Maternal use of alcohol during pregnancy and premature births has been attributed to congenital abnormalities such as fetal alcohol syndrome and intellectual and developmental disorders (IDD). Unfortunately, much of the research has not examined developmental disorders (e.g., autism disorder spectrum) separately. Although the effects of the No Child Left Behind (NCLB) Act remain to be determined, early research suggests that the policy is aversive to maintaining Native culture and effective learning outcomes for AIAN children. According to Balder and Grossman (2009), while teachers essentially supported NCLB’s efforts to focus needed attention on students, they also generally agreed the policy forces them to abandon pedagogical practices that they believe to be crucial in educating their children and sustain culture. In fact, teachers believe such restrictions on practices of implementing culturally and linguistically relevant instruction may result in more than academic failure of individual students, but such a curricular shift may be culturally catastrophic.
The reminder of this section will address select disabilities and chronic conditions that are prevalent among AIAN populations. It is important to note that not all disabilities are easily observable or observable at all. When discussing AIANs and types and frequency of disabilities, caution is in order because of their misclassification as either white or Hispanic and the common practice of collapsing existing racial categories into a single group of “other” (Centers for Disease Control and Prevention, 2003; Grandbois, 2005b).
Mental Health Disorders
Although tribal differences in the prevalence of certain mental health disorders exist, in general, AIANs have high rates of mental disorders , especially alcohol abuse and dependence, depression, and posttraumatic stress disorder (PTSD) (Beals et al., 2005, see Research Box 13.1). Research suggests that mental illness, mental dysfunction, or self-destructive behavior affects approximately 21% of the total AIAN population (Duran et al., 2004). AIANs’ rates of lifetime help-seeking behavior are generally low; they have higher dropout rates and are less likely to respond to treatment. In addition, the terminology of the Diagnostic and Statistical Manual of Mental Disorders (DSM) for diagnosis of mental illness disorder does not correspond with different expression of illness in Native languages. For example, the words “depressed” and “anxious” are not part of Native languages, whereas “ghost sickness” and “heartbreak syndrome” are used to describe symptoms and behaviors that are associated with the DSM diagnoses (National Alliance on Mental Health [NAMI], 2007). Because AIAN culture is holistic in nature, the physical, mental (cognitive), emotional, and spiritual aspects of a person are integrated, and the mind-body separation of western thought is inconceivable (Yurkovich & Lattergrass, 2008). According to Mehl-Madrona (1997), “all illness is an illness of the spirit that manifest itself in the body, mind, and emotions, and we all carry within our souls the capacity to heal ourselves” (p. 17). Many AIANs will seek assistance from designated tribal members who can address disharmony through sacred ceremonies. Others may seek treatment from both traditional healers and healthcare professionals. Ocampo (2010) cautions that the Eurocentric “mental health frameworks, when applied among First peoples, may result in further trauma and perpetuate, rather than address, their problems” (p. 3).
Research Box 13.1
See Beals et al. (2005).
Objective: To compare findings of the American Indian Service Utilization, Psychiatric Epidemiology, Risk, and Protective Factors Project (AI-SUPERPFP) estimates of the prevalence of DSM disorders and utilization of services for help with those disorders in American Indian populations and with the baseline results of the National Comorbidity Survey (NCS).
Method: A total of 3084 tribal members (a Southwest tribe and a Northern Plains tribe) ages 15–54 years living on or near their home reservations were interviewed with an adaptation of the University of Michigan Composite International Diagnostic Interview. The lifetime and 12-month prevalence of nine DSM disorders were estimated, and patterns of help-seeking for symptoms of mental disorders were examined.
Results: The most common lifetime diagnoses in the American Indian populations were alcohol dependence, PTSD , and major depressive episode. Compared with NCS results, lifetime PTSD rates were higher in all American Indian samples, lifetime alcohol dependence rates were higher for all but Southwest women, and lifetime major depressive episode rates were lower for Northern Plains men and women. Fewer disparities for 12-month rates emerged. Both American Indian samples were at heightened risk for PTSD and alcohol dependence but a lower risk for major depressive episode, compared with the NCS sample. American Indian men were more likely than those in NCS to seek help for substance use problems from specialty providers; American Indian women were less likely to talk to non-specialty providers about populations about emotional problems. Help-seeking from traditional healers was common in both American Indian populations and was especially common in the Southwest.
Conclusions: The results suggest that these American Indian populations had comparable, and in some cases greater, mental health service needs, compared with the general population of the United States.
- 1.
What mental health disorders were prevalent in American Indian reservation populations?
- 2.
To whom were American Indian women less likely to discuss about emotional problems?
- 3.
Which samples had heightened risk for PTSD?
- 4.
How did the American Indian reservation populations compare to the general population in the United States for mental health service needs?
Research suggests that living in a stressful environment, experiencing traumatic events, historical trauma , high rates of frequent distress, poverty, stigma associated with mental illness, and lack of access to mental health services contribute to negative mental health consequences for AIANs (De Coteau, Hope, & Anderson, 2003; Grandbois, 2005a, b). Events are associated with historical trauma are varied, however, share distinguishing characteristics. First, events are generally widespread among AIAN communities and, at the time of the event, result in many members of the community being affected by the events. Second, historical trauma is experienced at the individual, family, and community levels. Third, collectively the events produce high levels of distress that may translates into generational impact for AIAN populations (Brave Heart, Chase, Elkins, & Altschul, 2011; Cole, 2006; Whitbeck, Adams, Hoyt, & Chen, 2004). According to Big Foot and Braden (2007), the traumatic events endured during previous generations create pathways that increase the risk of mental and physical distress in the current generation and reduce their ability to solicit strength from their indigenous culture or benefit from their natural familial and tribal support system. In addition, many older AIANS (elders) experienced historical trauma (e.g., mistreatment, discrimination, forced relocation, loss of land, loss of people and family, and loss of culture) that may influence their attitudes and perceptions toward mental health services. According to Sotero (2006), the primary feature of historical trauma is that trauma is passed on to subsequent generations through biological, psychological, environmental, and social venues, resulting in a multigenerational cycle of trauma. The psychological concerns of historical trauma for AIANs are manifested as substance abuse (Chartier & Caetano, 2010; National Survey on Drug Use and Health, 2010), co-occurring disorders related to substance abuse and mental health disorders (Abbott, 2007), mood disorders and posttraumatic stress disorder (CDC, 2007; Dickerson & Johnson, 2012), and suicide (CDC, 2007). More often than not, mental disorders coexist with substance abuse disorders and suicide (discussed in the following sections) (Mason & Altschul, 2004).
Barriers to rehabilitation services for AIANs
Disjointed coordination among agencies Fragmentation of services across federal agencies and offices Lack of coordination and collaboration among federal, state, and tribal programs Federal travel and budget limitations Advocacy made difficult by multiple education systems (i.e., public, tribal, Bureau of Indian Affairs) |
Limited knowledge or understanding about tribal communities Lack of federal staff knowledge and training for federal personnel on the federal trust responsibility to AIANs and on tribal sovereignty Agency staff’s fear of the unknown and unfamiliarity with AIAN populations |
Limited enforcement of laws protecting people with disabilities on tribal lands Lack of clarity about legal enforcement options Failure to ensure that the national mandate to eliminate discrimination against individuals with disabilities included equal benefits for AIANs with disabilities |
Limited local tribal planning to protect and support people with disabilities Lack of involvement of tribal leaders and tribal members in the design, development, and implementation of programs Limited consumer involvement at all levels of policy development Difficulties in tribal/state relationships Limited tribal awareness and access to new strategies that can better serve people with disabilities Historical distrust of the Federal Government by tribal leaders and member |
Suicide
The suicide rate for AIANs of all ages is much higher than the overall rate in the United States. Suicide rates are particularly high for AIAN males ages 15–24, who account for 64% of all suicides by AIANs (Grandbois, 2005a, b; NAMI, 2007), and suicide is the second leading cause of death among AIAN people age 10–34 (CDC, 2010). There is considerable variation in the suicide rates of AIANs among different regions and different groups. AIANs’ most significant risk factors include alcohol and drug abuse, historical trauma , alienation, acculturation, discrimination, LGBT status, community violence, barriers to mental health services access and use, contagion, stigma, poverty, unemployment, exposure to suicide, rural/remote, racism, economic instability, loss or conflict of cultural values and attitudes, media influence, social disintegration , and relationship of risk factors (D’Oro, 2011; SPRC, 2013; Walker, Loudon, Walker, & Frizzell, 2006). For young males, the time of greatest of suicide is from adolescence to adulthood (Middlebrook, LeMaster, Beals, Novin, & Manson, 2001). In an earlier study, Freedenthal (2002) explored predictor factors to determine whether suicidal behaviors differ between reservation and urban AIAN youth and found substantially different factors initiate suicidal behavior between the two groups. Significantly more reservation youth than urban adolescents reported a history of suicidal ideation. The predictors for urban youth suicide attempts included a history of sexual abuse and a friend or family member having attempted or completed suicide. For reservation youth, the predictors included past or current depression, having no father in the home, cigarette smoking, and family history of drug abuse.
Although studies have not connected traditional child-rearing practices to suicide rates among AIAN youth, the awareness of whether those practices are consistent with traditional AIAN methods or in conflict with mainstream methods may help to provide some insight. Traditionally, AIAN children are taught independence by allowing for early personal responsibility. Mainstream culture may interpret early independence as permissiveness. Furthermore, having experience personal freedom at an early age, AIAN youth may have difficulties adjusting to rigid or restrictive rules and boundaries (Brown & Silva, 2011).
Substance Abuse
The ability to access information or data about AIAN substance use is restricted because (a) “AIAN reservations are sovereign nations and can in part determine what resources are used for data collection,” and (b) “tribal communities are often located in rural areas, it can be difficult to access comprehensive epidemiological data that are consistent for comparison across communities” (Rieckmann et al., 2012, p. 499). Nevertheless, some reliable data is available about substance use among AIAN adults, even if not differentiated by geographic area. AIANs have a long history of alcohol use, and today alcohol abuse and other drug abuse and dependence have produced disruptive effects and yield lifetime rates of substance use disorders (SUDs ), especially for AIANs that live on reservations or tribal lands (see Discussion Box 13.1). Moreover, the decimation of SUDs is evident throughout AIAN communities through the erosion of kinship obligations and associated adverse series of suicides, diabetes, accidents, cirrhosis, heart disease, and injuries (Gone & Calf Looking, 2011), and “literally no one is left untouched by the scourge of SUDs” (p. 292). Compared to the general population, more AIANs meet the criteria for alcohol and drug (AOD) use , alcohol disorders, and illicit drug use (i.e., marijuana, opiate pain medications, cocaine, hallucinogens, and stimulants) (Greenfield & Venner, 2012; Substance Abuse and Mental Health Services Administration, 2007). The National Survey on Drug Use and Health (NSDUH, 2010) estimated that the percentage of AIAN adults in need of substance abuse treatment was higher than the national average, yet AIAN adult admissions were lower than other adult admissions. The Treatment Episode Data Set (TEDS) also revealed that although the criminal justice system is the most frequently reported source of referral for all adult substance abuse treatment admissions, AIAN adult admissions are referred by the criminal justice system at a higher rate than other admissions (SAMHSA, 2010).
AIANs are more at risk for alcohol-related consequences compared to the general population. Although the statistics range across various studies, compared to the general population AIANs are significantly more likely to die from alcohol-related deaths, including automobile accidents, suicide, homicide, and chronic liver disease and cirrhosis. AIAN men are more likely than AIAN women to die from alcohol-related causes, and fetal alcohol spectrum disorder ( FASD) is considerably higher for AIAN women than non-AIAN even though AIAN women have a lower rate of alcohol use, except binge drinking (NSDUH, 2010; Zahnd, Holtby, & Crim, 2002). Binge drinking is more common among AIANs living in poverty than in the general population living in poverty (NSDUH, 2010; SAMHSA, 2011). Although a greater percentage of AIAN adults abstain from alcohol than non-AIAN adults, their disproportional alcohol-related consequences suggest that AIANs those who do use alcohol consume at exceptionally high levels. Conversely, AIAN youth drink more than non-AIAN youth (NSDUH, 2010). AIAN youth alcohol consumption rates are higher than rates of all substance used combined (alcohol, tobacco, and other drugs when compared to national averages (NSDUH, 2011). According to Stanley, Harness, Swaim, and Beauvais (2014), the prevalence rates of substance abuse for AIAN students living on or near reservations were significantly higher than national rates for nearly all substances, especially for eight graders. Marijuana uses was very high, with lifetime use higher than 50% for all grade groups, and binge drinking rates and OxyContin use were high for AIAN students.
Discussion Box 13.1
The use of alcohol by AIANs has a historical context that is grounded in European colonization. The production of fermented beverages by AIANs was used for ceremonial purposes. For the most part, AIANs were unfamiliar with distilled beverages (more potent alcohol). Distilled beverages were introduced to AIANs and used by European colonists as a medium of trade. No guidelines, laws, or social mores were established in either the distribution or use of distilled beverages. Traders also found that providing free alcohol during trading sessions gave them a distinct advantage in their negotiations (Beauvais, 1998). The outcome was devastating to young AIAN men, who often had control over the furs and skins being traded. Trading for alcohol left AIAN tribes in a state of poverty, which in turn undermined their efforts to cope with European colonialism (Quintero, 2001). Often extreme intoxication was commonplace among colonists, which became a powerful model for social use of alcohol among the inexperienced AIANs. Displays of violent drinking bouts were common among AIANs, colonizing traders, military personnel, and civilians (Beauvais, 1998).
- 1.
What extent do historical events contribute to alcohol abuse among AIANs?
- 2.
How did modeling of drinking behavior impact AIAN drinking patterns?
- 3.
How can historical events influence current drinking behavior of AIANs?
As with any population, the reasons for alcohol and other drug (AOD) use are varied; however, causal explanations for AOD abuse for AIANs are highly correlated with genetic and predisposition factors (Ehlers, n.d.), social and cultural influences (e.g., socioeconomic, loss of culture, boarding school experience, colonization) (Westermeyer, 2004), and personal attitudes toward alcohol. Early research suggests that AIAN drinking behavior is often attributed to stress and historical trauma (Belcourt-Dittloff & Stewart, 2000; Mail, 1989). Other explanations of high AOD use among AIANs in rural areas include the harshness of reservation life, isolation and rurality of reservations, modeling behavior (i.e., everyone around you drinks), high unemployment, easy availability and access, and stereotype of the “drunken Indian.”
Rieckmann et al. (2012) found that urban AIANs who were polysubstance users or had a history of abuse more frequently reported employment problems, and reservation-based AIANs reported having more severe medical problems and a greater prevalence of psychiatric problems (see Research Box 13.2). Beyond being Indian-owned and not using medications to treat substance use disorders, a comparison of substance abuse treatment for rural programs and urban treatment centers reveals distinct differences. Rural programs are located in a plain state; offer a 28-day residential program including individual counseling, group counseling, and marriage and family counseling; are spiritually based treatment facilities; and admit persons aged 18 years and older who are enrolled in the tribe and have a primary problem with AOD. The urban facility offers a continuum of mental health and substance abuse treatment services including residential family treatment, outpatient services, transitional housing for women and children, and primary healthcare clinic and is not restricted by race or ethnicity or AIAN client’s self-identify; length of stay in residential treatment can last up to 6 months, and parents are able to bring their children up to the age of 5 years to treatment (Rieckmann et al.).
Research Box 13.2
See Rieckmann et al. (2012).
Objective: To address the research gap to prepare descriptive analyses of patient populations in the south central plains reservation-based treatment program and urban treatment program in the Northwest.
Method: The Western States Node of the National Institute on Drug Abuse Clinical Trials Network partnered with two American Indian substance abuse treatment programs to compare assess client characteristics, drug use patterns, and treatment needs. Additional sub-analysis examined patients reporting regular opioid use and mood disorders.
Results: Urban clients (n = 74) were more likely to report employment problems, polysubstance, and a history of abuse. Reservation-based clients (n = 121) reported having more severe medical problems and a greater prevalence of psychiatric problems. Client who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems.
Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessment of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AIAN clients seeking treatment for substance use disorders.
- 1.
How can knowledge of substance use trends and patterns be used to inform treatment?
- 2.
Which psychiatric disorder was elevated in the combined sample of urban and reservation-based AIANs?
- 3.
What does the study confirm about the need for comprehensive intake procedures?
AIAN adults and youth in rural, plain states , and tribal lands or Indian country continue to have higher rates of substance abuse disorders, and substance abuse co-occurring with suicide for youth is extremely high. Gaining insight into the rate of substance abuse among AIANs may be linked to understanding their health behaviors and practices. It is important to note that health behaviors are not merely what people do but how they are impacted by a host of co-occurring factors. The interaction of these factors means that AIANs are simultaneously at risk for all of them, creating a potentially severe network of social and psychological risks that affect their overall health (Native Vision Project, 2012).
Health Behaviors
Health behavior is a particularly important focus for rural populations in general; however, for AIANs understanding the relationship between chronic disease, disability, and healthcare is crucially important. The health outcomes of AIANs are affected by a host of interacting factors including social and cultural barriers, racial and ethnic biases and discrimination, patient health behaviors, environmental factors, delivery of healthcare in a culturally appropriate manner, language, poverty, and low education attainment. In addition, structural barriers such as management of different types of Indian Health Service (IHS) services, geographic location, wait time, age of facilities, provider turnover rates, retention and recruitment of qualified health providers, misdiagnosis or late diagnosis of disease, and rationing of health services adversely impact AIANs’ health outcomes as well (US Commission on Civil Rights, 2004). The health status of AIANs is further complicated by a lack of health insurance coverage. Zuckerman, Haley, Roubideaux, and Lillie-Blanton (2004) found that 49% of AIANs have private insurance coverage as compared to 83% for Caucasians. More recent data indicate that for AIANs under age 65, 28.3% are without insurance (National Health Interview Survey, 2014). Often, availability of insurance influences access to and utilization of healthcare services.
AIANs experience disproportionate effects of various diseases that may be linked to risk behaviors such as tobacco use, AOD abuse, high-calorie, high-fat diet, and physical inactivity (Barnes, Adams, & Powell-Griner, 2010; Chino, Haff, & Dodge-Francis, 2009; Cobb, Espey, & King, 2014). The patterns of health risk behaviors for chronic disease for adolescent AIANs living on reservations are consistent with those of adult AIANs. Conversely, health risks for rural, non-reservation AIAN adolescents in the areas of physical health, substance abuse, emotional health, and risk of injury were average or better health habits, with some difference by gender and age (Gray & Winterowd, 2002). Cobb et al. found that these behavioral risk factors were consistent with observed patterns of mortality and chronic disease among AIANs. Because one of the leading causes of death for AIANs is chronic disease, knowledge of family history of these chronic conditions may be important in identifying those at greatest risk for developing the disease (Slattery et al., 2009). As with any individual, knowledge of family history may be important in the health behaviors of AIANs for several reasons: (1) screening recommendations may change based on family health history, (2) determining family history of disease may identify individuals who would benefit the most from adopting a healthy lifestyle or who are at risk because of an unhealthy lifestyle, and (3) educating directly at altering lifestyle characteristics associated with such a disease could reduce an individual’s risk of developing it (Slattery et al.; Yoon, Scheuner, & Peterson-Oehike, et al., 2002). In their study of AIANs health behaviors, Slattery et al. found that obesity, physical activity, cholesterol, and perceived health were associated with family history and concluded that individuals with a family history of diseases may have lifestyles that influence their disease risk. Yet, these behavioral risk factors all are amenable to public health intervention (Cobb et al.).
Regardless of whether the health issue is physical or mental , AIANs’ help-seeking behaviors emerged as two central categories: health engagement strategy and avoidant strategy (Yurkovich, (Hopkins) Lattergrass, & Rieke, 2012). In Yurkovich et al. study, health engagement strategy was used for the establishment of mental wellness and its maintenance. Health engagement strategy identified seven practices . The first is spiritual activities, which included ceremonies related to Native American Indian traditions. The second is talk with someone, which included the use of the formal (i.e., professional practitioner) and informal healthcare systems (i.e., elders, family). Third, the practice of meaningful doing or purpose is used, in which the purpose for their existence was significantly intertwined with meaningful doing. The fourth practice, use medication, had mixed reviews by the participants. On the one hand, participants took their medication because it was helpful. On the other hand, participants experienced difficulty in finding the right medication, and psychiatric visits for medication were sporadic, brief, and focused on medication supervision with little time for talk therapy. The use of solitude is the fifth practice and is different from isolation and is perceived as benefiting their ability to deal with stress and creates a healing environment to reduce or control symptoms. The sixth practice, learning about their illness, is for participants that had been in treatment programs that focused on teaching them about their disease and how to manage it, expressed feelings of empowerment by this knowledge, and confidence in their ability to stay in balance. The final practice is performing health physical behaviors and was recognized as significant to maintaining their wellness because they knew of the connection between their physical state of being and their ability to stay mentally or emotionally balance (i.e., wholeness) (Yurkovich et al.) (see Yurkovich et al. for further explanation).
Avoidant behaviors occurred most often when there had been ongoing unresolved problems. These behaviors were seen as the person’s best coping strategy for the emotional level being experienced and the immediate context of the problem. Avoidant behaviors themselves may have been barriers to choosing healthier behaviors (Yurkovich et al., 2012). Avoidant behavioral strategy included five practices. The first avoidant behavior practice is substance abuse, which is for the purpose of self-medicating and temporarily eliminating memories of trauma, betrayal, losses (recent and distant), or abuse. The second strategy of avoidance is suicidal behaviors related to a sense of hopelessness, poverty, unemployment, and intergenerational depression. The practice of nonengagement in therapy is the third avoidant strategy in which participants did not engage in talk therapy for a lengthy time period because of cultural influence, stigma, and lack of understanding its full purpose and benefits. The use of this strategy was also exhibited in their discontinuance of therapy once their crisis or pain was under control. Denial of symptoms and treatment needs is the fourth avoidant practice, which supports the cultural beliefs of being strong and independent and fixing it themselves. In addition, cofounding factors such as not knowing what was wrong, how to deal with it, and who to seek for assistance were manifestations of denial. The final practice of avoidant behaviors is leaving the reservations. This practice was seen as positive in supporting their sobriety. Leaving the reservation was useful to their maintenance of wellness (Yurkovich et al.).
Another important issue with impact on the health behavior of AIANs is stereotypes of healthcare providers. Bean et al. (2014) found that despite being highly motivated to treat AIAN individuals (and Hispanics) fairly, the majority of nursing and medical students reported awareness of stereotypes associating these patient groups with noncompliance, risky health behavior, and difficulty understanding and/or communicating health-related information. Negative attitudes of healthcare providers are as significant a barrier as the avoidant behavioral strategies of AIANs themselves.
The interplay between barriers to treatment (e.g., access, distance, wait times, personnel shortage) may also influence health behaviors for AIANs. Many AIANs reported having no health plan and no personal doctor, despite living in counties generally served by IHS. The relationship of income to health behaviors was examined by Wolfe, Jakubowski, Haveman, and Courey (2012), and they found that an association with a tribe with Class III gaming leads to higher income, fewer risky health behaviors, better physical health, and perhaps increased access to healthcare. In comparison to the general population, AIANs face many health challenges because of their higher rates of risky health behaviors, poor health status and health conditions, and lower service utilization (Barnes et al., 2010). Moreover, because of the enormous costs of chronic disease and premature death of AIANs, federal and tribal agencies charged with improving the health of AIANs should focus on strengthening primary prevention (Cobb et al.).
Service Utilization and Barriers
Worldviews that impact mental healthcare
AIAN | Majority culture |
|---|---|
Relations, circular | Linear, point A to B |
Holistic | Specialization |
Mystical/acceptance | Scientific/verification |
Ceremonials/rituals | Psychotherapy |
Collectivism | Individualism |
Spiritual and balance | Organized religion |
Cooperation | Competition |
Patience | Assertive |
Presented oriented | Future oriented |
Herbs, plants, nature | Psychopharmacology |
Intuition and vision | Expertise and planning |
Wellness, peace, balance | Cure |
Being-in-becoming | Doing |
Harmony with | Mastery over |
Nonverbal | Expressive |
Mason and Altschul (2004) identified several barriers to service utilization for AIANs. First, the majority of the IHS budget is devoted to the provision of acute healthcare services , which, in conjunction with the paucity of mental health professionals, result in primary care physicians as the principle source of detection and treatment of mental health and AOD problems. Second, in every IHS service area, the ration of providers to population is well below accepted standards. Third, the IHS’ financial resources have not increased relative to inflation in almost four decades. Fourth, there is difficulty in recruiting a sufficient number of primary care physicians, which creates a problem of delivery of services by nonpsychiatric physicians.
AIAN tribes are sovereign governments , and relationships between tribes and states can be strained because of overlapping or conflicting jurisdictions (NCD, 2003a). Federal laws enacted to protect persons with disabilities are not always enforceable against tribal governments because of the sovereign immunity and sovereign status of tribal governments (NCD, 2003b). The poor health of AIANs is further hampered by their inability to access specialty care, in part because of Contract Health Services (CHS) limitations (pays for patient care at non-IHS facilities when services are not available through the local IHS) and lack of other sources of insurance, and a lack of specialty medical services on or near reservations (Baldwin et al., 2008). Although “the Affordable Care Act (ACA) offers important opportunities to increase health coverage and care for AIANs and reduce longstanding disparities they face,” half of poor uninsured AIANs live in states not moving forward with Medicaid expansion at this time (Henry J. Kaiser Foundation, 2013, p. 1). The end result is that many AIANs will continue to face the gap in coverage since they will remain ineligible for Medicaid, and those below the federal poverty level will not be eligible for tax credit subsidies for marketplace coverage. It is noted that because Medicaid is a federal program, states must consult with tribes before they can make changes in their Medicaid programs that affect tribal members.
Beyond issues of availability, access, costs, and organizational and infrastructure barriers, many cultural beliefs of AIANs (see Table 13.1) can become barriers to service utilization either because of AIANs’ beliefs and practices or service providers’ misunderstanding. For example, the emphasis on living in the presence is often misinterpreted by service providers as indifference and irresponsibility. Often, cultural beliefs and practices in tandem with service providers’ lack of understanding of AIAN culture lead to poor communication and misinterpretation of behavior. Although they are not required to accept the Native ontology, epistemology, or social constructs, rehabilitation counselors, healthcare providers, and other human service professionals need to understand and respect the complexities of AIAN cultural practices and their influence to improve client outcomes (Lovern, 2008). In western society when counselors subscribe to the notion that the person of minority status should adapt to that of the majority status and acts on the expectation that the therapeutic process and goals are the same regardless of culture and geography, the outcomes for the client are usually negative. The level of acculturation and the degree to which AIANs identify with the values of the larger society or those of the Native culture should always be considered. In addition, level of acculturation is likely to guide selection of therapeutic interventions and vocational counseling goals (Sue & Sue, 2013). Research suggests that when AIANs feel that their worldview is not respected, they may simply out of services altogether (Simms, 2009; Sue & Sue, 2013; Oetzel et al., 2006).
A continual barrier to service utilization by AIAN communities is their historical cultural mistrust of the outside populations and non-AIAN health services. As a result of this mistrust, many AIANs use traditional healing (NAMI, 2007). Although most AIANs see the potential benefit of counseling only when it is entered into freely and not mandated, resistance to formal treatment is often culturally rooted in concerns and mistrust of past government intrusions into Indian life (Beals et al., 2005; LaFromboise, 1988; Urban Indian Health Institute, Seattle Indian Health Board, 2012).
Cultural values also act as a barrier in the willingness of AIANs to seek help for mental health issues. Typically, AIANs refrain from in-depth, one-on-one self-disclosure within clinical settings. Thus, group counseling is more successful than individual counseling (Lokken & Twohey, 2004). Concerns for privacy is another cultural barrier. Other cultural barriers include a cultural norm of politeness and respect that may result in not directly discussing signs of depression and cultural preferences for restoring well-being (Oetzel et al., 2006). In general, mental illness stigma exists in the United States, and the role of culture is important with regard to stigma, particularly for ethnic minority groups (Abdullah & Brown, 2011).
Repeatedly, research demonstrates that culture plays a crucial role in wellness and significantly affects help-seeking behaviors, treatment regimens, treatment compliance, response to and management of pain, illness, and disability (Cross & Day, 2015; Gray & Rose, 2012; Simms, 2009). Rehabilitation counselors and other service providers will need to find ways to turn cultural barriers into assets in the service delivery process. Clearly, “the strengths and resilience of AIAN people provide opportunities to support positive change and positive community-sanctioned outcomes” (Cross, Friesen, & Maher, 2007).
Recommendations for Effective Vocational Rehabilitation Intervention
In the planning and delivery of rehabilitation services for AIANs, there is no “one size fits all” in how disability is viewed in AIAN communities or how AIAN individuals access services and supporters. In addition, the size and complexity of the particular tribal government and its infrastructure figure into determining the relationship of an AIAN individual and community has to disability and disability-related services and supports (Cohen et al., 2012). Health and human services policy for AIANs comprise “a complex history, and it is a collection of sometimes conflicting federal Indian law, health policy, and intergovernmental relationships…” and “severely underfunded health services” that have led “to severe AIAN health disparities” (Warne & Frizzell, 2014, p. 266).
According to Gray and Rose (2012), “most indigenous approaches for interpersonal interaction begin with the relationship, knowing a person, developing trust, and respect for the individual that fits well with Western interpersonal approaches” (p. 82). Moreover, tribal cultures and values vary greatly from traditional to acculturated, and individual tribal members may fall anywhere along or outside of the continuum between these cultures; it is important for counselors to understand how the AIAN client relates to culture and identity (Gray & Rose). To best provide services to AIANs, counselors and other practitioners must develop an understanding about the cultural practice and beliefs of AIAN populations. In fact, professional license certification organizations have requirements for cultural competency of practitioners when working with diverse populations. Retention in treatment and services is directly related to cultural competence within service provision structures (CI). According to Yurkovich and Lattergrass (2008), “to provide culturally competent care professionals and native healers need to work the integration of spirituality into treatment processes, and advocate the creation and maintenance of healthy environments for improved social opportunities” (p. 437).
Thomason (2011) conducted a survey of mental health and related professionals who have extensive experience with Native Americans to identify practices counselors and psychologists should employ to make sure their work with Native Americans clients is culturally appropriate and effective. The counselors and psychologists were asked to respond to 30 questions, including several closed-end questions and many open-ended questions about how to improve services for AIANs. Some of the general findings were as follows. First, half of the respondents believed that Native American counselors are more effective than non-Natives, while 20% said there is no difference, 18% said it depends on the cultural competence of the counselor, and 12% said it depends on how traditional is the client. Second, the counselor should ask AIANs what they need and how the counselor can help, seek to speak with tribal elders, and offer refreshments. The counseling setting should be inviting with Native art. Third, incorporate spirituality into counseling and/or determine if it is important to the client. Fourth, it is inappropriate for non-Native counselors to use Native health practices because it may be seen as patronizing. Using Native health practices may be look upon favorably if it is done cautiously and if the counselor has been trained in the methods and has tribal approval. Otherwise, it is best to refer the client to a Native counselor or healer. Fifth, psychological testing should be done carefully with due consideration of how the client’s culture may affect the results. Finally, in the first session to build rapport, the counselor should (a) welcome the client warmly, (b) offer refreshment, (c) minimize intake paperwork, (d) invite the client to describe the problem or issue from his or her perspective, (e) use self-disclosure to elicit client talk, (f) address the role of culture in the client’s life, (g) talk about confidentiality and expectations for counseling, and (h) let the client determine the content of counseling sessions. Overall, the findings suggest that building trust with AIANs is best accomplished through genuine empathy, self-disclosure, understanding the client’s acculturation, and cultural competence and involvement in the local tribal communities.
Just as there are guidelines for incorporating AIANs’ cultural values and practices into service delivery, essential awareness and sensitivity to myths and stereotypes are equally necessary. For example, the following types of statements are based on stereotypes and should be avoided: (1) can I talk to the chief (2) what is your Indian name, (3) ask them if they know an AIAN person that you know, and (4) I have seen “Dances with Wolves” (Brown & Silva, 2011). Too often stereotypes continue to thrive because they are based on historical assumptions about AIANs and a lack of information about AIANs’ present lives and circumstances. Counselors and other service providers can defuse stereotypes by checking their own beliefs and unconscious biases.
Although a variety of traditional counseling theories and techniques can be used with AIAN populations, the client-centered model of Carl Rogers (1961) was recommended more often than any other approach (Thomason, 2011). However, several process-oriented aspects of the approach create barriers for effective use with AIANs. First is the importance and centrality of the client-counselor relationship, which questions whether such a one-on-one interaction outside the context of family and community is a pragmatic means of dealing with AIAN clients’ problems. The focus on client individuality fails to take into account the role that the client has within the family or community (LaFromboise, Trimble, & Mohatt, 1990). LaFromboise et al. recommend social learning theory deals better with cultural norms because of its focus on teaching appropriate everyday skills and behavior to clients through the use of modeling and rehearsing activities. The strengths of the social learning approach are it is less culturally biased and allows the community to define the community-level target problems to be solved, thus not imposing the standards of the dominant culture. In addition, social learning lends itself to prevention efforts in that it can address potential problems before they develop. Finally, the extensive use of role modeling is a major source of learning in AIAN culture and is both consistent and reinforcing of that extended family tradition (LaFromboise et al.). Other recommended approaches are cognitive behavioral (Jackson, Schmutzer, Wenzel, & Tyler, 2004), motivational interviewing, narrative therapy, and Jungian or “adapted Jungian approach (Duran & Duran, 1995). LaFromboise et al. offer both advantages and disadvantages of behavioral approaches. The advantages of behavioral approaches are in the action-oriented focus on the present rather than on the past, and they lend themselves to implementation by paraprofessionals and in prevention-oriented interventions. A major disadvantage with both behavioral and social learning approaches is the potential misuse when the goals of the client are not the goals targeted for change in therapy or when behavior change processes are controlled by counselors who do not respect the client’s goals (LaFromboise et al.).
In an effort to integrate traditional AIAN values and indigenous problem-solving mechanisms into the counseling process, network therapy is similar and consistent with the more traditional AIAN community-oriented interlocking network of family, kin, and friends (LaFromboise et al., 1990). In network therapy (support network), the client’s issues are treated within the context of a larger family and community social system, which allows the symptoms to be considered form multiple angles including their functional roles or consequences within a specific system (e.g., workplace, family, community). Network therapy offers the advantages of being applicable in any setting, utilizes natural supports, and is less intimidating than one-on-one client-counselor office interaction (LaFromboise et al.). Refer to the case study to consider the application of various counseling approaches and how to work with the client.
Case Study
The client is a 37-year-old single Navaho woman named JoyWonder, who grew up on a reservation. She is able to read and write and completed high school. Her employment history consists of being a cook and dishwasher in a small nearby town. While at work 1 day, a customer asked her if she ever thought about living off the reservation and moving to the city. The customer worked at the local hospital 30 miles away as a nurse and suggested to JoyWonder that she should consider getting a job as a nurse’s aid at the hospital. The customer provided her with information about training.
Upon returning to the reservation that evening after work, JoyWonder presented the idea of moving to the city to her family. She was met with stiff opposition. The family told her of all the bad things that could happen to her in the city. The elders told her that if she moved away, she would be considered dead to the family.
Against the advice of her family and elders, JoyWonder moved to the city. She had lived in the city for 18 months before returning to the reservation for a visit. JoyWonder was confronted with rejection and was told that she now belonged to the white man’s world.
- 1.
Which counseling approach would you use with JoyWonder?
- 2.
What cultural issues should be addressed?
- 3.
What interpersonal barriers between the counselor and JoyWonder should be addressed?
- 4.
How would you involve the family and community in the counseling process?
Intervention approaches and programs for AIANs with substance abuse problems have been implemented, but have yielded less than satisfactory results (Hawkins, Cummins, & Marlatt, 2004; Whitbeck, Walls, & Welch, 2012). Some researchers have suggested that a lack of compatibility exists between the theories used for prevention programs in AIAN communities and culturally appropriate AIAN worldviews (Champagne, 2007).
Walsh and Baldwin (2015) conducted a systematic review of the literature to assess substance abuse prevention (SAP) efforts for AIAN communities from 2003 to 2013. The focus was to assess program impacts and outcomes, common problematic elements, and theories that guide programming. The authors found that overwhelmingly the majority of programs were targeted toward AIAN youth and adolescents followed by a combination of individuals, families, and communities, with only one designed explicitly for adult women. Program focus was primarily on prevention, and only a few explicitly focused on alcohol use or abuse and rarely did programs address other behaviors. Frequently programs took place as in-school and/or curriculum-based interventions. The methods used to implement the programs varied widely, ranging from a curriculum to life skills-building activities as a main approach. The common cultural elements integrated, adapted, or tailored into the programs included AIAN teachings, involvement of tribal community members or leaders, AIAN core values, and cultural enrichment exercises. Some programs explicitly described cultural elements to include talking circles, AIAN languages, and sweat lodge ceremonies. Almost all of the programs reported positive outcomes, which were categorized as specifically showing increases in knowledge of substance abuse, overall negative attitudes toward substance abuse, refusal skills, general self-efficacy or confidence of participants, negative social normative beliefs toward substance abuse, awareness of substance abuse, decreases or delays in alcohol or other drug abuse, and combination of the previous outcomes. Fewer of the programs (39%) used theory compared to 61% that did not. Of programs that used theory, theories included social cognitive, Cherokee self-reliance, community empowerment theory, cultural compatibility theory, cognitive theory, cultural historical theory, community competence theory, ecological risk theory, and resiliency theory (Walsh & Baldwin). Walsh and Baldwin concluded that to effectively address the high rates of substance abuse of AIANs, there is a need to understand why certain SAP programs work in Native communities. To accomplish this, theoretical underpinnings of program development should be linked to with appropriate measures and ensuring accurate program evaluation. Moreover, an assessment of SAP program evaluations in Native communities, regardless of theory inclusion, is necessary to understand differing cultural practices and their influence on theoretical fit between smaller reservation tribes and non-reservation and urban AIAN tribes (Walsh & Baldwin).
Cultural adaptations to treatment
When assessing the history and cultural context of the client, it is important to understand his or her perspective and the problem or issue How would the client’s problem be explained in his or her culture? Is the problem within the medical, magical, religious, biographical, or educational context? How would the problem be treated by traditional healers within the client’s culture? What is necessary to return to a sense of balance? |
Work collaboratively with traditional healers if this is important to the client It is good to know what kinds of practices they use Respect that ceremonies and treatments will be kept private within the culture, and it is impolite to intrude without invitation or to pursue information if the client is hesitant to provide it Ask in a way that provides the client an opportunity to give only as much information as he or she may be comfortable providing Understand that food and water are considered medicine in many AIAN cultures because it is an important aspect of keeping life in balance |
Understand how the client expresses emotions Asking how men or women in their culture express feelings (e.g., anger, shame, guilt, fear, disgust, joy) gives the emotion a cultural context Follow by asking how the counselor would recognize these feelings in the client’s expressions. It may be necessary to access how the emotions may be expressed in their family or tribe |
Counselor’s attitude and the counseling environment are paramount and should include the counselor’s willingness to self-disclose (appropriately) and collaborate with the client while demonstrating regard and respect The counselor should include information about how he or she knows his or her field The counselor’s lack of knowledge about the client’s culture The counselor’s willingness to learn, if the client will teach Regard and respect may be established by asking about traditional greetings, such as a soft, gentle handshake as opposed to the Western firm handshake Check to see if the client has a preferred way to be identified culturally The environment should be physically welcoming (e.g., sage, sweet grass, AIAN art) |
Before closing discussion of vocational rehabilitation implications for working with AIANs , some mention of attitudes toward work is warranted, especially because employment is the primary objective of vocational rehabilitation services. Traditionally, work for the sake of working was unusual because nature provided for needs. Thus, punctuality is less familiar to AIANs. Work always has a distinct purpose and is interwoven with spirituality harmony and balance (Brown & Silva, 2011). The cultural values (see Table 13.2) of AIANs may present some obstacles to employment in occupations or settings that require supervision of others or competition. Therefore, the rehabilitation counselor or job placement specialist will need to use AIANs’ cultural values as assets in job matching and placement. AIANs on reservations and in rural areas or plain states are generally more traditional and thus less likely to participate in modern industries and economic activities, or less educated and skilled, and thus less able to obtain positions or advance beyond low-level jobs.
Overall, before rehabilitation counselors and other practitioners can employ any type of intervention strategy for working with AIAN populations with disabilities, they should have some prerequisite knowledge that can improve their ability to provide effective and relevant services. In addition to those life issue differences previously mentioned in this chapter, practitioners should operate on the notion that all people deserve respect (Ft. Peck Reservation Focus Group, 1996), contextualize their outreach and education efforts to accommodate cultural differences, recognize the historical dependence on federal programs by AIAN people can be a disincentive to participation in other programs (Brown & Silva, 2011), and identify cultural attributions about the causes of physical and mental health problems and cultural attributions about the solutions to physical and mental health problems (Atkinson, 2004). To facilitate rehabilitation counseling, healthcare, and mental health outcomes of AIANs in rural areas, the counselor must be able to approach services from the worldview of the client and promote informed choice.
Policy and Future Implications
AIAN health policy
Snyder Act (1921) – the first law that allowed Congress to appropriate funds to address AIAN health on a recurring basis. The funding authority for many of the current activities of the HIS is rooted in this act |
Transfer Act (1954) – the Indian health program became the responsibility of the public health service under this act. A transfer of health needs to any health facility cannot be made without approval by the governing body of the tribe (tribal sovereignty and tribal self-determination). The authorities were also transferred to the Secretary of Health, Education, and Welfare (now Health and Human Services) |
Indian Self-Determination and Education Assistance Act ( ISDEAA ) (1975) – the basis for authorizing tribes to assume the management of BIA and IHS programs, and it directs the Secretaries of Interior and Health and Human Services to enter into self-determination contracts at the request of any tribe. In terms of health services, any program, function, service, or activity of the IHS can be assumed by the tribe under a “638 contract” |
Indian Health Care Improvement Act ( IHCIA ) (1976) – was instrumental in setting national policy to improve the health of Indian people because the language regarding the responsibility of the US government to improve the health of AIAN people enhanced the intent of previous laws by expanding and describing modern health services. Title V of IHCIA established the urban Indian health programs. The act also included the initial authorization that allowed IHS and tribal 638 health programs t bill Medicare and Medicaid |
Affordable Care Act ( ACA ) (2010) – expanded Medicaid. Requirement of health insurance companies to pay for preventative services and cancer screening |
Permanent Reauthorization of the IHCIA (2010) – permanently reauthorized as part of the AC in March 2010. Includes several modifications designed to improve the provision of health services to AIANs. Authorizes Congress to appropriate resources to meet goals |
Several policy recommendations have implications for AIAN populations. Duran (2005) suggested, “in this era of evidence-based, reforms to AIAN health policy are essential steps toward remediation and reconciliation practice” (p. 758). Duran’s recommendations are offered based on existing facts about AIAN healthcare policies and services. The first fact is that AIAN health professionals provide the most culturally competent care in rural areas. The recommendation is to fund more Native-specific health career opportunity programs. Fact number two is that Native rural and urban communities are poised to conduct community-based participatory research (see Chap. 38) with Native scholars and other enlightened scholars in academia. Thus, the recommendation is to fund more community-based participatory research efforts such as the Native American Research Centers for Health initiatives. The third fact is if given sufficient resources, space, and time, Native communities with Native scholars can propose and test culturally sound and evidence-based public health policy. Clearly, the recommendation is to increase Indian Health Services (IHS) funding to 100% of the level of need to support AIAN self-determination efforts (Duran). The National Congress of American Indians (NCAI, 2012a) strongly recommends that tribes receive direct and adequate funding to provide culturally appropriate services that empower their citizens with disabilities to lead independent lives in their own communities.
The ACA offers opportunities to increase coverage and access to care for AIANs; however, half of poor uninsured adult AIANs live in states not moving forward with the Medicaid expansion at this time and, as such, will continue to face a gap in coverage. States do not have optional authority to require AIANs to enroll in Medicaid managed care organizations (MCO) , unless the MCO is operated by the IHS, a tribe, or an urban Indian health program. In addition, the marketplaces provide new coverage options for many AIANs, but only members of federally recognized tribes will receive certain consumer protections (Henry Kaiser Foundation, 2013). Although new and expanded policies exist, the implication is that many AIANs will continue to be underserved.
The Supreme Court ruling in 2012 that the ACA is constitutional sustains permanent reauthorization of Indian Health Care Improvement Act (IHCIA) . If the Supreme Court had ruled that ACA was un-severable, which would have made the entire law null and void, that would have erased significant strides made through the IHCIA by (a) terminating ongoing feasibility, (b) obstructing enrollment of tribal employees in the Federal Employees Health Benefits Program, and (c) endangering current implementation efforts by IHS, the Department of Veterans Affairs, and the Department of Health and Human services (NCAI, 2012b). At the writing of this chapter, the United States is in the midst of a presidential election. Although it is not known who will win the presidency, the general consensus is that if the Republican candidate wins, the unraveling of the ACA begins, and “the loss to tribal communities would be tremendous and permanent reauthorization of the IHCIA would be undone” (National Congress of American Indians, 2012b, p. 2).
Summary
AIAN populations represent diverse groups with different, yet overlapping and shared cultural values, beliefs, and practices. They share many of the same historical injustices, healthcare inequities, barriers of isolation, and gaps in resources, especially on or near reservations and in rural areas. In addition, AIAN tribes promote many of the same strengths and resilience for survival. AIAN people are among the most highly vulnerable populations, which increase substantially by economic vulnerability. Understanding how to address the physical and mental health needs of AIANs is best approached from an understanding of their culture. Throughout this chapter great emphasis has been placed on the practice of respectfulness of tribal sovereignty, culturally relevant approaches to services, and involvement of elders in the development of solutions to address the needs of tribal members. In addition, discussion explicitly conjoined healthcare and disability because of their cyclical nature. The future of tribal healthcare and permanent reauthorization of IHCIA is uncertain and more likely will not prevail if the ACA is un-servable.
Resources
American Indian Disability Technical Assistance Center: http://aidtac.ruralinstitute.mt.edu
Consortia of Administrators for Native American Rehabilitation (CANAR): http://www.canar.org
Indian Health Service: http://www.ihs.gov
Native American Advocacy Center: http://www.nativeamericanadvocacy.org
Native American Disability Law Center: www.nativedisabilitylaw.org
National Congress of American Indians: http://www.ncai.org
Office of Minority Health: http://www.omhrc.gov
Understanding Disabilities in American Indian and Alaska Native Communities: Toolkit Guide: www.ncd.gov/rawmedia_resitory/53edc4ab_c8c7_4786_8f04_35a40855075c.pdf
Tribal Epidemiology Centers. (2013). Best Practices in American Indian and Alaska Native Public Health: http://www.glitc.org/forms/epi/tec-best-practices-book-2013.pdf