Behavioral Health Services for American Indians and Alaskan Natives
SAMHSA TIP 61
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counseling Education
Host: Counselor Toolbox Podcast
CEUs are available at: https://allceus.com/member/cart/index/product/id/1114/c/
Objectives
– Addiction and mental health professionals will improve their understanding of:
– American Indian and Alaska Native behavioral health.
– The importance of cultural awareness, cultural identity, and culture-specific knowledge when working with clients from diverse American Indian and Alaska Native communities.
– The role of native culture in health beliefs, help-seeking behavior, and healing practices.
– Prevention and treatment interventions based on culturally adapted, evidence-based best practices.
– Methods for achieving program-level cultural responsiveness, such as incorporating American Indian and Alaska Native beliefs and heritage in program design, environment, and staff development.
Factoids
– 22% of AI/AN live on reservations. 60% live in urban areas
– There are more than 200 tribes in Alaska.
– The term “Eskimo” is considered derogatory
– Health solutions come from within the community using local models
– 25% of AI/IN live in poverty in comparison with 13% of the general population
– Fewer than 50% of AI/AN women who experience violence report it, and of those only 10%-40% of cases are ever prosecuted.
Factoids
– Education protects against substance abuse, depression, suicidality, and other behavioral health problems for American Indians and Alaska Natives, as well as for other populations, yet they are less likely than the general population to graduate
– AI/AN typically define family as extending beyond the nuclear unit
– About half of American Indian and Alaska Native households include members of the extended family, and one-quarter include people who are not directly related.
– About 30 percent of American Indian and Alaska Native families are headed by single mothers. Grandparents also often raise children
Factoids
– Not all native cultures are the same. Similarities exist, but each nation may have its own beliefs and traditions
– AI/AN are less likely to drink than White Americans; however, those who do drink are more likely to binge drink and to have a higher rate of past-year alcohol use disorder than other racial and ethnic groups.
– AI/AN experience anxiety disorders at a higher rate than other Americans
– Native youth have a much higher suicide rate than youth or adults of other races more than double those for the U.S. population
– Suicide and suicide attempts among young men ages 15–24 account for nearly 40 percent of all suicide deaths among natives.
Factoids
– Likely reasons for today’s high rates of substance use, suicide, and domestic abuse among AI/AN are that their communities are exposed to a greater degree to the same risk factors that are predictors of problems for everyone: Poverty, unemployment, trauma (including historical trauma), and a loss of cultural traditions.
– Maintaining ties to one’s culture can help to prevent and treat substance use and mental disorders
– Among many Native Americans, substance use and mental disorders are not defined as diseases or character flaws. They are seen as a symptom of an imbalance in the individual’s relationship with the world.
Historical Trauma
– One of those causes of imbalance stems from wide spread abuses and injustices experienced by AI/AN
– Loss of their communities
– Loss of life
– Loss of freedom
– Loss of land
– Loss of self-determination
– Loss of traditional cultural and religious practices
– Practicing many cultural traditions was illegal for AI/AN from 1878 until 1978.
– Loss of native languages
– The removal of children from their families
Factoids
– Historical trauma has been defined as the “cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma”
– It is critical to incorporate the role of historical trauma in assessments, in developing treatment plans, and in implementing healing strategies
– Historical trauma may be different from other trauma in that that the distress resulting from the trauma is collective rather than individual, and the cause of trauma comes from people outside the community affected by it
– Trauma can affect future generations physically (e.g., by raising the risk of certain diseases), socially (e.g., by increasing child abuse and domestic violence), psychologically (e.g., by causing depression or PTSD), and spiritually (e.g., by losing hope)
Historical Trauma
– How historical trauma is transmitted across generations through its effects on parenting.
– Brave Heart (1999) suggests that trauma experienced by parents can:
– Disrupt traditional parenting practices
– Increase substance abuse, mental health and physical health
– Affect trust and intimacy and the ability to form a healthy bond with one’s children
– Cause secondary traumatization when parents tell stories of historical events or of their own experiences
– Children also witness and, to some extent, internalize their parents’ reactions in times of stress when their parents’ responses to traumatic situations are triggered.
Historical Trauma
– The concept of historical trauma
– Is intended to help the provider, find ways of discussing current trauma and emotional or behavioral problems in a context that is not “stigmatizing”
– Presents trauma as a collective experience, and thus one that communities can work together to overcome
Initial Meeting
– As a provider, it is important to promote, support, house, and help facilitate the development of prevention activities in native communities
– When meeting, give your name and job title, explain briefly something about yourself, what you are doing, and why.
– Take your cue from clients when it comes to offering a handshake and expect that it may be very light as a sign of politeness and respect
– Keep your eye contact brief until you observe the habits of your clients.
– Confidentiality is huge
Assessment
– During the assessment
– Explore and assess cultural identity
– Obtain clients’ perspective first.
– What caused the problem and the decision to enter treatment
– What thoughts do they have about how to return to a more balanced state.
– Ask what clients already know about their problem and what they have tried
– How do they see the problem-
– How does it affect different aspects of their lives
– What do they need to do to heal
– What does successful healing look like for them
– Identify treatment goals that are important for your clients
– Incorporate cultural activities and or AI/AN healers in treatment planning if the client wishes
Treatment
– Creating culturally responsive services requires the participation of the native community, including leaders (formal and informal), councils, clients, potential clients, and client families.
– Avoiding community participation represents an example of paternalism, in which providers assume that they inherently know what is best for the program, client, staff, and community.
– AI/AN beliefs revolve around the value of connectedness and the importance of relationships. If providers do not build relationships or demonstrate interests in the community, the native community may be less accepting of the services offered
– Culturally responsive services will likely provide clients with a greater sense of safety and support the belief that culture is essential to healing.
Treatment
– Healing and treatment approaches need to be inclusive of all aspects of life incorporating the spiritual, emotional, physical, social, behavioral, and cognitive.
– Healing can come from reconnecting to strengths inherent in traditional teachings, practices, and beliefs and begin to walk in balance.
– The division between physical and behavioral health is not one that is typically recognized. One aspect of health is believed to affect the other.
– A health problem that affects one person will have effects on a family, community & tribe
– Prevention and treatment are seen as part of the same process
– Illness is the reflection of imbalance or disharmony
– Healing the community can positively affect individual health and that the process of healing may need to occur at the community level to be effective for the individual
Treatment
– An illness may occur because an individual or relative has broken some cultural or natural law, recently, in the past, or in a previous generation. Because of this, a person may be held
at least in part responsible for developing an illness, and the individual who has the illness
may see it as his or her responsibility to bear the symptoms.
– An illness may also be personified in the sense that it has a spirit, and that spirit may need to be addressed as part of the healing
– Traditional practices often increase social support, thereby improving health
– Healing rituals improve participants’ coping abilities and quality of life. Traditional healers have stories that guide individuals on how to handle various problems.
Treatment
– Traditional healing helps individuals transcend their experiences by identifying the meaning and purpose of those experiences within the context of the community, including the environment.
– Some traditional healing rituals alter participants’ consciousness, which in turn can produce a spiritual transformation that affects overall health.
Traditional Healing Practices
– Offering tobacco with one’s prayers, often done in a group.
– Burning herbs or smudging for purifcation
– Participating in a talking circle, where an object is passed allowing everyone to express feelings and thoughts.
– Giving herbal medicines.
– Performing a sweat lodge or spirit lodge to experience purifcation, prayer, and healing and improve emotional and physical well-being.
– Performing tribal dances
– Chanting and singing in groups which can go on for days.
– Creating medicine bags that hold specific meaning for the owner.
– Engaging in other traditional ways, such as carving, tanning hides.
– Using humor to address and survive many difficult situations
Commonalities
– AI/AN believe that they are only one part of creation, dependent on nature, and meant to live in harmony with all things
– Native Americans believe in the importance of balance/harmony:
– Internally for the individual
– Socially among people
– Naturally in relationships with animals and the rest of creation
– Community norms and values play an important role in all aspects of life for AI/AN, including treatment for and recovery
– Involving family and community in the development of treatment programs is important in providing effective services for most.
– It is important to ask about their families and their willingness to be involved in treatment
– Shame is a strong factor preventing service access
Spirituality
– 79.2 percent of AI/AN ages 12 to 17 in 2014 stated that religious beliefs are an important part of their lives and believed their beliefs shape decisions
– Having a stronger commitment to traditional spirituality is a protective factor against suicide and some mental and substance use disorders
– Many AI/AN are Christians, but incorporate aspects of native beliefs which may affect their view of the world and their place in it
– The Navajo concept of hozho means peace, balance, beauty and harmony. To be “in Hozho” is to be at one with and a part of the world around you. When two people are parting they may say, “May you walk about according to hozho.” In part, it is a reminder to go about life deliberately. The Diné (Navajo) Hózhó Wellness Philosophy
Alaskan Native Values
– Show respect to others: Each person has a special gift.
– Share what you have: Giving makes you richer.
– Know who you are: You are a reflection on your family.
– Accept what life brings: You cannot control many things.
– Have patience: Some things cannot be rushed.
– Live carefully: What you do will come back to you.
– Take care of others: You cannot live without them.
– Honor your elders: They show you the way in life.
– Pray for guidance: Many things are not known.
– See connections: All things are related
Traditional Values
– Cooperation, collectivism, harmony
– Modesty and humility
– Respect for personal freedom and autonomy (Trust each other to do right, don’t give advice)
– Respect tradition and elders.
– Emphasis on oral tradition.
– Work to meet needs not accumulate wealth
– Respect for generosity
– All of nature is alive and worthy of respect
– Value present-focus (mindfulness) and patience
Interventions
– Motivational Interviewing
– Use model adaptations appropriate to your population
– Have clients create personal stories for each stage of change
– Present the stages of change model as a circle
– Native American Motivational Interviewing: Weaving Native American and Western Practices—A Manual for Counselors in Native American Communities (Venner et al. 2006)
– Trainer’s Guide to Motivational Interviewing: Enhancing Motivation for Change—A Learner’s Manual for the American Indian/ Alaska Native Counselor (Tomlin, Walker, & Grover, 2014)
– Trauma Informed Approaches
– Historical Trauma and Unresolved Grief Intervention (Brave Heart, 1998)
Interventions
– Mindfulness Based Interventions
– Use walking meditations
– Explore how to use mindfulness in traditional practices
– Acceptance and Commitment Therapy uses mindfulness, value-based decision making and purposeful behavior
– Cognitive Behavioral Therapy interventions should assume the role of consultant and resource provider and avoid being too directive
– Cognitive–Behavioral Therapy With American Indians (McDonald & Gonzales, 2006)
– Cognitive–Behavioral Therapy for Native American Youth With PTSD Symptoms (Goodkind, LaNoue, & Milford, 2010)
Summary
– Historical trauma including the loss of culture lies at the heart of substance use and mental illness
– Behavioral health issues are seen as an imbalance in the individual’s relationship with the world.
– Healing and treatment approaches must be inclusive of all aspects of life—spiritual, emotional, physical, social, behavioral, and cognitive.
– Providers need to understand how clients perceive their own cultural identity and how they view the role of traditional practices in treatment.
– Reconnection to American Indian and Alaska Native communities and traditional healing practices, may help individuals reclaim the strengths inherent in traditional teachings, practices, and beliefs and begin to walk in balance and harmony. (if they want)
Summary
– Providers in native and non-native programs need to understand the role of tribal sovereignty and governance systems in treatment referrals, planning, and program development.
– American Indian and Alaska Native clients and their communities must be given opportunities to offer input on the types of services they need and how they receive them.
– Culturally responsive counselors will explore how culture affects their interactions, their initial and diagnostic impressions of clients and selection of healing interventions.
– An environment that reflects American Indian and Alaska Native culture is more engaging for, and shows respect to, clients who identify with this culture by using native community vendors, hiring a workforce that reflects local diversity, and offering professional development activities (e.g., supervision, training) that highlight culturally specific American Indian and Alaska Native client and community needs
Summary
– There is no one right way. Providing direction on how something should be done is not a comfortable or customary practice for American Indians and Alaska Natives. For them, healing is interconnected with others and comes from within, from ancestry, from stories, and from the environment.
RESPECT
– Respect communication styles and how respect is shown in the culture
– Explanatory model: Understand how clients perceive/understand their presenting issues
– Sociocultural context affect treatment
– Participation expectations for treatment may be different than mainstream. (family, community, faith healers etc.)
– Empathy
– Concerns and fears should be elicited (at the beginning and at points of resistance)
– Trust is based on who you are not what you accomplished.
Sources: Bigby & American College of Physicians, 2003; Campinha-Bacote et al., 2005
Other Resources
– https://www.samhsa.gov/capt/sites/default/files/resources/factors-substance-abuse-mental-health.pdf
– https://www.samhsa.gov/capt/sites/default/files/resources/strengths-address-alcohol-suicide.pdf
– https://www.samhsa.gov/sites/default/files/combined_suicide_resources_overview.pdf
– https://store.samhsa.gov/product/American-Indian-and-Alaska-Native-Culture-Card/SMA08-4354
– https://store.samhsa.gov/system/files/sma16-4970.pdf
– https://www.samhsa.gov/tribal-affairs
– http://wellbriety.com/