Native American Mental Health
I. Defining Native Americans
- There are an estimated 2,500,000 American Indian, Eskimo, and Aleutian people living in the U.S. (U.S. Census, 2006)
-In addition to these figures, another 1,800,000 people report having Native American heritage. (U.S. Census, 2006).
- For a Native American population there is the unique problem of trying to defining what constitutes being Native American and self-report census information can be highly variable and skewed. (Snipp, 1986)
-There is much debate and many legislative disputes about what constitutes being Native American. According to Congress a person must have a blood degree of at least 25 percent to be considered Indian American. But many tribes have specified their own criteria of tribal enrollment or blood line percentage. (Sue & Sue, 2008)
A. Cultural Identification
-Degree of acculturation plays an important role in the level of individuals identifying with being Indian American.
-A study by M.T. Garrett and Pichette (2000), proposed categories of cultural identification to include: traditional, marginal, bicultural, assimilated, and pantraditional.
-Before the 1830’s Native American tribes lived all over the United States hunting, gathering, and farming off the land.
-In 1830 (the Removal Period) Native American tribal lands were opened up to farming for white settlers, displacing over 125,000 Indians to reservations in what is now Kansas and Oklahoma. (Potawatomi.org, Sue & Sue, 2008)
-Many tribes were forced to live together, regardless of tribal differences.
-Life on the reservation was also colored by a period of white socialization in which Native American children were removed from their families and sent to boarding schools for 8 years. At these boarding schools they were not allowed to speak their Native American languages and were taught white culture. (Dlugokin & Kramer, 1974).
-These boarding schools resulted in a loss of Native American culture and identity of Indians who came back from these schools removed from their own culture and unable to pass down traditions and values to the next generation. (Dlugokin & Kramer, 1974).
-The Native American, Eskimo, and Aleutian population is made up of 561 different tribes all with unique cultures. (Sue & Sue, 2008)
-The five biggest tribes are the Cherokee, Navajo, Sioux, Chippewa, and Choctaw tribes. (U.S. Census Bureau, 2006).
-Reported by the U.S. Census Bureau (2006):
-the average income is 62 percent of that of the U.S. average
-the poverty rate is twice as high as the national average
-only 11 percent have a bachelor’s degree compared to the 24 percent average
- 28 percent of NAs still spoke a NA language in the household
- 33.5% of Native Americans live in tribal areas as compared (64.1% live outside tribal areas)
IV. Prevalence of Psychiatric Diagnoses in American Indian (AI)/Alaska Native (AN)
- Most common Axis I lifetime diagnoses in AI/AN are alcohol dependency (27-37% lifetime prevalence for all substance abuse disorders), major depressive episode, post-traumatic stress disorder
- AI/AN are at increased risk compared to the general population for alcohol dependency and PTSD
- AI/AN are at decreased risk for major depressive episode
B. Alcohol Dependency
- Alcohol Dependency in AI/AN (other drug use is less than general population)
o Low percentage of individuals consume alcohol
o Highest rates of heavy drinkers (26%+) than general population
- The age-adjusted death rates due to alcohol dependence in AI/ANs have been reported as more than 7 times higher than that of the U.S. All-Races rate. In AI/AN adults aged 25-44, alcohol is associated with the two leading causes of mortality: accidents and chronic liver disease/cirrhosis. (IHS, 2001)
- Data on alcohol use and abuse in AI/AN communities are often misleading. These populations have the lowest overall rates of individuals who consume alcohol but concomitantly have the highest rates of “heavy drinkers” (defined as binge drinking 5 times a month or more) among those aged 26 and older (Substance Abuse and Mental Health Services Administration, 2002)
o Death rates due to alcohol dependence is 7X higher than general population
o Two leading causes of mortality in those aged 25-44 are accidents and chronic liver disease/cirrhosis
o The 1997 arrest rate among American Indians for alcohol-related offenses (driving under the influence, liquor law violations, and public drunkenness) was more than double that found among all races.
o High co-morbidity between substance disorders and depressive and/or anxiety disorders
- “For an alcoholic, the culture is alcohol. The last thing to come back is often spirituality. When a person is drinking, they have no culture but drinking.”
C. Major Depressive Disorder
- Most studies suggest that depression is less prevalent in IA/NA – this has led to an attempt to evaluate the instruments used to screen for depression
- Despite the use of more sensitive instruments lower than natural averages are diagnosed
- Comorbidity with alcohol dependency is high
- 28% of patients with diabetes have major depressive disorder (prevalence of type 2 diabetes is 4 to 8 times higher in AI/AN than the general population
D. Post-Traumatic Stress Disorder
- Prevalence of lifetime PTSD in one tribe was 21.9% (N=54)
- 81.4% of the subjects (N=201) had experienced at least one traumatic event apiece
- The most predictive factor among women was the experience of physical assault
- The most predictive factor for men were a history of combat and having experienced more than 10 traumatic events (Robin, Chester, Rasmussen, Jaranson, & Goldman, 1997)
- 61.4% of AIAN women reporting physical assault, 34.1% reporting rape, and 17.0% reporting stalking during their lifetime
- American Indians, experience per capita rates of violence, which are more than twice those of the U.S. resident population. 120 v 55/1,000 persons aged 12 and over
- American Indians between ages 18 and 24 experienced the highest per capita rate of violence of any racial group considered by age & about 1 violent crime for every 4 persons of this age. 1992-96 (1/3rd of all violent incidents)
V. Help- Seeking Behaviors
- Use of traditional healing rituals and services is positively linked to strength of one’s ethnic identity (Goldston, 2008)
- Culturally traditional healing services (family members or traditional healer) were thought to be more effective than professional services on or off the reservation (Walls, 2006)
- It is possible that an increasing number of people are seeking traditional healing services to avoid the stigma that is associated with psychiatric services (Goldston, 2008)
- American Indian adolescents sited stigma and embarrassment as reasons for not seeking help when suicidal. It may be difficult to seek help confidentially in a small, isolated community (Goldston, 2008)
- Native Americans with comorbid disorders (substance disorders with depression and/or anxiety) sought services more often than those with depression and/or anxiety, or substance disorders alone (Beals, 2005)
- Help seeking from traditional sources was more common in the Southwest tribe than in the Northern Plain tribe for any disorder (Beals, 2005)
- Overall help seeking for any disorder was more common in the Southwest tribe than in the Northern Plains tribe (Beals, 2005)
- Native Americans were less likely to seek treatment from specialty or other medical providers for depressive or anxiety disorders (13%) than the general population (30%) (Beals, 2005)
- Native Americans were more likely to seek treatment from specialty providers for substance use disorders (20%) than the general population (7%) (Beals, 2005)
- Mental health services have continued to impose the mainstream diagnostic categories and treatments on Native American communities with the false belief that these services are universal (Dana, 2000)
- During the intake interview, American Indians struggled with determining the co-occurrence of symptoms used to diagnose a major depressive episode; they had difficulty understanding the time frame in which their symptoms occurred (Beals, 2005)
- The complex wording of diagnostic interview questions may present significant difficulties cross-culturally (Beals, 2005)
- In the American Indian culture the needs of the group are placed before the needs of the individual; counselors generally encourage Native American clients to think for himself and consider their own feelings, which are both counter to their values (Wasinger, 2003)
- Interference in another’s affairs is discouraged in the Native American culture; therefore an Indian client may resent a therapists attempt to help with their personal problems; therapists should proceed slowly with their clients (Wasinger, 2003)
- Silence and remaining quiet are also common values within the culture; Native Americans may be perceived as inattentive or slow (Wasinger, 2003)
- In the American Indian culture nonverbal behavior is quite different from non-Indian communication styles; for example, avoiding direct eye contact (Wasinger, 2003); the therapist should follow the clients lead regarding nonverbal behaviors (Thomason, 1991)
- Native Americans believe that “one is continually in a state of being rather than becoming;” therapists must keep this in mind when creating therapeutic goals and tasks (Wasinger, 2003)
- Relaxed, casual, non-threatening environment
- Conversational verbal style; avoid questions in the beginning so the client doesn’t feel pressured to disclose personal information, use self-disclosure
- Determine how traditional the client’s values, tribal identification, current comfort with cultural identity, support system, counseling expectations
- Possibly visit the client’s reservation to experience their culture
- Take an active, directive approach that focuses on the present more than the past or future, and emphasizes practical problem solving
- Steer away from nondirective, client-centered, analytic approaches
Patient identification. M. is a 24-year-old American Indian married woman, the mother of two daughters, ages 5 and 7, by a previous marriage. M. and her family live on a reservation in Washington State.
History of present illness. Over a year before her presentation, M.'s paternal grandmother died. Several years ago M. was diagnosed with alcohol dependence, but she has been sober and drug free for three years. She relapsed nine months after her grandmother's death. At the suggestion of an AA friend, M. stopped drinking and attended a bereavement support group. M. stopped after 4 sessions because she felt that she experienced her loss very differently from the non-Indian group members: no one else spoke of seeing the deceased after the funeral like M. had. She felt she could not share how she occasionally still heard her grandmother's voice "speaking Indian" to her. A tribal elder woman, named S. told her that other tribal people sometimes had similar experiences after losing a loved one. M. was instructed on how she could actively help the family prepare the memorial dinner for her grandmother. The dinner and accompanying ceremonies marked the end of the bereavement period, and S. assured M. that the prayers would be strong and would result in putting away her grief "in a good way." After the memorial dinner M. felt much less sad and had more energy, but four months later she presented herself at the tribal mental health clinic. M. said that for the past month she experienced frequent crying and occasional rages. Nearly every day she felt very sad all day long and she had great difficulty in keeping to her daily routine. She had trouble concentrating on her school assignments. M.'s supervisor at the fast food restaurant where she works remarked about her recent slowness and forgetfulness on the job. In the past two weeks, M. called in sick four times even though she was not sick. She wanted to stay home and sleep most of the day. She experienced a marked decrease in her appetite. She was more bothered than usual by the occasional lower back pain which was the sequelae of an automobile accident three years earlier. Despite past traumas (childhood sexual abuse and spouse abuse in adulthood), M. denied symptoms persistent and intrusive re-experiencing of the trauma, stimuli avoidance, and increased arousal.
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