Native mental health: Issues and challenges

BANGOR, Maine - For hundreds of years American Indians have suffered genocide, relocation, and cultural disenfranchisement. Yet, Native people prove to be among the world's most resilient. Unfortunately, the many years of atrocities combined with current conditions such as an unemployment rate 10 times the national average has lead to a particularly significant number of mental health challenges.

For example, the Native suicide rate is twice that of the general population and alcoholism rates are six times the national average. Alcohol abuse contributes to significant health problems such as a terminal liver cirrhosis rate 14 times that of the rest of the nation and infants born with fetal alcohol syndrome and fetal alcohol effects.

A complicating factor in enhancing mental health wellness among Native peoples is the high treatment drop out rates among Natives and their hesitancy to enter treatment. To a large degree these problems are rooted in a historical distrust of the majority population and the shortage of Native mental health providers. Most Natives would prefer to receive services from other Natives. An equally significant problem lies in the lack of knowledge non-Native providers have regarding Native culture. While there is great diversity among Native peoples in regards to language, customs, socioeconomic status and levels of acculturation there is some measure of significant commonality among Natives which are disparate from the majority culture. Indigenous peoples set a high priority on extended family, cooperative interdependence, the cyclical nature of time and working with nature. These differences can contribute to poor therapeutic relationships if these cultural differences are viewed by the treating therapist as dysfunctional family ties, lack of ego boundaries, therapeutic resistance, or passivity. To avoid this possibility the American Psychological Association has stipulated guidelines on multicultural education, training, research, practice and organizational change. The latest version of these guidelines was published in May 2003 and, in summary, explicitly states the need for psychologists to be aware of their own cultural biases, encourages knowledge and understanding of ethnically different groups, and use of culturally appropriate skills. However, far more educational programs focusing on Native issues are required in order to better equip non-Native providers. Of particular relevance would be the proliferation of trainings which would include individuals selected by Native communities as trainers regardless of the presence or absence of letters after their names. For example, pipe carriers, clan mothers, indigenous healers and other cultural leaders would provide much needed training for non-Native providers and add a richness of experience that otherwise would be unobtainable. Individual state licensing boards should be encouraged to recognize these Native leaders as legitimate trainers and provide the participants with continuing education credits.

While there is certainly some commonality between Natives and non-Natives in terms of risk factors for mental illness, there is enough uniqueness in the Native experience to view mental health problems through a more specific set of theories. For example, Dr. Eduardo Duran has written extensively about a "soul wound." He argues that a significant amount of Native mental health problems arise from hundreds of years of trauma. The emotional reactions to these traumas reside in the collective unconscious psyche of Native people and are manifested in the disproportionately high rates of some mental health problems.

His ideas can be viewed as a variant of Transgenerational Post Traumatic Stress Disorder; the notion that individuals can be affected by the traumas of their ancestors. He states that the only way a therapist can genuinely help the Native population is to adopt a Native world view. This is certainly a challenging task for those who hold a non-Native world view and argues strongly for cultural understanding on the part of the therapist.

Another important theory used to understand Native mental health issues is that of internalized oppression. This theory states that Natives have been oppressed for hundreds of years and as a group have taken into their own psyche the characteristics of the oppressors resulting in the tendency to oppress themselves even in the absence of an identifiable external oppressor. For example, for many years government and religious entities have attempted by various means to destroy the Native way of life, thus oppressing them. Even if government or religious entities stop oppressing Natives, Natives have learned through a variety of means and for a variety of reasons to oppress themselves.

While both of these theories hold important contributions, I believe that a healthy sense of Native identity is the most curing element in treatment. Unfortunately, through hundreds of years of trauma a healthy sense of Native identity has been severely jeopardized. Fortunately, there have been remarkable gains made in the last 25 years to re-establish Native pride and self esteem. Current psychological treatment must include traditional aspects of Native life to maximize effectiveness. For example, using talking circles when doing group work, including sweat lodge and smudging ceremonies among others, using the Medicine Wheel to understand ourselves, storytelling, language and pow wows are invaluable interventions. Indigenous healers must be included and they must be reimbursable by the insurance industry. While IHS recognizes these needs, many Natives are unable to use IHS services because they reside outside of a reserve's catchment radius or are Canadian Natives. Since a majority of Natives reside off reserve many can not avail themselves to culturally-based treatment. For example, there are no urban Indian centers in all of Northern New England. Clearly, advocacy efforts are needed to guarantee the best quality of care for each American Indian.

Dr. Kindya is the founder and CEO of Epiphany Consulting Group, which provides psychologically, and culturally sound services and training in mental health, prevention, substance abuse and community building. He has done numerous presentations on these topics for IHS and other professional groups. In the past, he co-founded a Native mental health center and served as its clinical director for five years. He has lived and worked among the Wabanaki people of Maine and Canada for 13 years.