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Lateffa Carter King, MSW

Continuing Education Information

In order to use culture as a positive force in change and empower individuals to be resilient to the stressors in their environment, mental health services must be accessible, appropriate, and culturally-relevant. To deliver such services to any particular group, clinicians must understand the complex relationships between that group’s contextual history, culture, and current mental health issues. Specifically, the history of any underserved cultural group can provide clinicians with a framework within which to fairly and accurately assess, diagnose, and treat members of that group. Effective services can only be provided given that the clinician 1) possesses necessary cultural competencies, 2) utilizes culturally-sensitive psychotherapy strategies relevant for that group, and 3) employs indigenous systems to compliment traditional service provision.
This paper explores how mental health service providers can develop these proficiencies to meet the mental health needs of American Indians/Alaska Natives.

Contextual History and Cultural Background 

The United States (US) Census Bureau estimates that 4.1 million American Indians and Alaska Natives lived in the US in 2000, representing less than 1.5 percent of the total US population. This population is a heterogeneous grouping of more than 500 federally recognized tribes and includes people identifying themselves as Hispanic and/or multiracial members of this group. Those identifying solely as American Indian or Alaska Native comprise less than 1 percent of the US population. Most American Indians live in western states, including California, Arizona, New Mexico, South Dakota, Alaska, and Montana, with 42 percent of this population residing in rural areas, compared to 23 percent of whites. For the purposes of this paper, the following terms will refer to this population: American Indian, Native people, and indigenous people.
The number of American Indians living on reservations and trust lands (areas with boundaries established by treaty, statute, and executive or court order) has decreased tremendously in the past few decades. For example, most American Indians lived on reservations or trust lands in 1980; while today, only 1 in 5 American Indians live in these areas. Furthermore, more than half live in urban, suburban, or rural nonreservation areas. It is the social and political history of Native people and their relationship to the US government that define their distinctive place in American life (U.S. Department of Health and Human Services, 2001).

American Indians and Alaska Natives flourished in North America for thousands of years before Europeans colonized the continent. Early European contact in the 17th century exposed Native people to infectious diseases which caused the population to plummet. As Europeans moved westward through the 19th century, the battles for Indian lands reduced the population to 5% of its original size by the early 1900s. In the 20th century, American Indians experienced both progress and hindrances: in 1924, Congress granted U.S. citizenship to American Indians; however, over the following 20 years, Federal services were withdrawn and Federal trust protection was removed from tribal lands.

One policy which proved damaging to Native communities was the mandatory boarding schools for American Indian children to obtain formal education. American Indian parents were forced to send their children to these schools, in which they experienced disconnection and devaluation of their culture, as well as physical and sexual abuse. Another dehumanizing policy from this period was the attempt to extinguish Native spiritual practices. Participation in traditional spiritual ceremonies was prohibited until the American Indian Religious Freedom Act was passed in 1978. Despite these prohibitions and the Christianization movements, indigenous spiritual practices have survived and are widely embraced even in areas where Christianity is practiced by Native people (Todd-Bazemore, 1999, as cited in DHHS, 2001).

The tremendous loss of lives, resources and forced movement to reservations and other Federal policies have had long-term economic and social effects. Brave Heart and DeBruyn (1998) suggest that social problems within the community are primarily the product of a legacy of chronic trauma and unresolved grief across generations. This phenomenon, which the authors labeled, historical unresolved grief, contributes to social pathology, originating from the loss of lives, land, and vital aspects of Native culture as a result of the European conquest of the Americas. Furthermore, these researchers argue that without a commitment to healing the past, American Indian/Alaska Native communities will not be able to address the resulting trauma, prevent the continuation of such carnage in the present, nor provide positive and healthy community activism to stop the prevalence of pathologies such as suicide, alcoholism, and domestic violence (Brave Heart & DeBruyn, 1998).

American Indians/Alaska Natives are the most impoverished of current minority groups, with over one quarter living in poverty, compared to 8 percent of whites. Furthermore, while comprising less than 2% of the US population, it is estimated that American Indians/Alaskan Natives comprise 8% of the homeless. In 1997, an estimated 1 out of every 25 American Indian/Alaskan Native adults were housed in the criminal justice system. Many American Indians and Alaska Natives are unemployed or hold low-paying jobs. In 1988, both men and women were twice as likely as whites to be unemployed (DHHS, 2001).

In 1990, 66 percent of American Indians and Alaska Natives 25 years old and older had graduated from high school or achieved a higher level of education. Despite these advances, the figure is well below that for the US population (75 percent). They were not as likely as others in the US to have completed a bachelor’s degree or higher. They appear to achieve equally with non-Indian students in elementary school, but decline in performance between fourth and seventh grades (Barlow & Walkup, 1998, as cited in DHHS, 2001).

Mental Health of American Indians/Alaskan Natives 

The Indian Health Service (IHS) was established in 1955 as a Federal agency with primary responsibility for delivering health and mental health services to American Indians/Alaska Natives. The IHS clinics and hospitals are located on reservations, yet the majority of American Indians no longer live on them. Today, the HIS remains primarily responsible for the mental health care of American Indians and Alaska Natives. Until 1965, mental health service delivery was sporadic. Congress has enacted and amended legislation to authorize comprehensive mental health services for tribes several times, but consistently failed to appropriate the necessary funds for this legislation (Nelson & Manson, 2000, as cited in DHHS, 2001).

The academic achievement gap is paralleled by a similar trend in mental health status among children and adolescents. One indicator of psychological well being is the suicide rate, which is 50 percent higher than the national rate (DHHS, 2001). A survey from the National School-Based Youth Risk Survey in 1997 indicated that American Indian and Alaska Native youths engaged in more risky behaviors overall than white and black youth (Young et al., 2001). The suicide rate is particularly high among young Native American males ages 15 to 24. This age group accounts for 64% of all suicides committed in the American Indian and Alaska Native population. The rate in this group is 2 to 3 times higher than the national rate (May, 1990; Kettle & Bixler, 1991; and Mock et al., 1996, as cited in Gary, Baker, & Grandbois, 2005). In a survey of American Indian adolescents, researchers found that 22% of females and 12% of males reported having attempted suicide at some time in their lives; while 67% of those who had made an attempt had done so within the previous year (Blum et al., 1992, as cited in Gary, Baker, & Grandbois, 2005).

Two recent studies have examined the need for mental healthcare among American Indian children and adolescents. One study conducted in the Great Smoky Mountains region of the United States, assessed psychiatric disorders among American Indian children ages 9 to 13 years old. Overall, American Indians were found to have fairly similar rates of disorder when compared to similar age white children from surrounding areas. However, American Indian children had higher rates of substance abuse or dependence when compared to white children (1% vs 0.1%, respectively). The difference in substance abuse was almost completely accounted for by alcohol use among 13 year old Indian children (Costello et al., 1997, as cited in DHHS, 2001).

In another study, researchers considered school-based psychiatric epidemiological study with American Indian youth from the Northern Plains in the United States. The five most common disorders reported were alcohol dependence or abuse, attention deficit and hyperactivity disorder, marijuana dependence or abuse, major depressive disorder, and other substance dependence or abuse. In addition, researchers observed a considerable amount of comorbidity among disorders. Specifically, more than half of the participants with a disruptive behavior disorder and 60% of youths diagnosed with a depressive disorder also qualified for a substance abuse disorder (Beals et al., 1997, as cited in DHHS, 2001).

In a sample from two American Indian reservations in the Southwest, Beals, Manson, Whitesell, Spicer, Novins, and Mitchell (2005) found that approximately 36% of women and approximately 50% of men (aged 15-54 years) reported overall lifetime prevalence of DSM-IV diagnoses. Alcohol abuse and dependence was the most common for men and posttraumatic stress disorder was most prevalent for women. Furthermore, the authors found significant levels of co-morbidity between individuals with depressive and/or anxiety and substance disorders. Similarly, results from Beals, Novins, Whitesell, Spicer, Mitchell, and Manson (2005) found that the most common lifetime diagnoses in the American Indian populations were alcohol abuse and dependence, posttraumatic stress disorder (PTSD), and major depressive episode. American Indian men were more likely to receive help from specialty providers for substance abuse issues, while American Indian women were more likely to seek help from non-specialty providers about emotional problems.

Issues of Substance Use and Abuse within Native Communities

Substance abuse problems are most common among males and young to middle age adults, with high problem rates persisting until about 45 years of age when rates begin to drop off. This drop off may be due to men eventually stopping their drinking as they begin to take on responsibilities associated with being an elder, and women ceasing to drink heavily when they see their behavior is inconsistent with the behavioral expectations they have for their children. The reasons for drinking also may differ for women in that they may be more likely to develop problem use while in relationships with substance abusing men or use alcohol as a means of coping with the negative feelings associated with victimization, grief, and loss. Many American Indian women who seek substance abuse treatment have a history of trauma including domestic violence and childhood sexual abuse (Brindis et al., 1995, as cited in Herman-Stahl & Chong, 2002). Because elders are less likely to drink, there may be more stigma associated with seeking treatment or consulting elders about drinking problems (Herman-Stahl & Chong, 2002).

Clinicians must be aware of the long, tumultuous history Native Americans have with alcohol. American Indians had little exposure with intoxicating beverages prior to the introduction of alcohol by European settlers, traders, and travelers (Beauvais, 1998, as cited in Herman-Stahl et al., 2003). Furthermore, historical accounts suggest that Europeans pressured Native Americans to drink in order to seal trade agreements and/or to celebrate special occasions (May, 1989, as cited in Herman-Stahl et al., 2003). Historians also propose that after being forced onto reservations and alienation from traditional work, many American Indians used alcohol to relieve boredom and as a means of coping with feelings of despair (Mail & Johnson, 1993, as cited in Herman-Stahl et. al., 2003). As drinking in the Native American communities became more pervasive, European settlers passed colonial laws which prohibited the sale of alcohol to them. Prohibition was enforced until 1953, and, ironically, many tribes still maintain dry policies.

Alcohol dependence with a co-morbid disorder is a significant problem impacting American Indian and Alaska Native adults, as well as youths. Estimates of psychiatric disorders among American Indians with substance abuse problems range from 35-60%. Available data suggests that co-morbid psychopathology is at least as prevalent in American Indian/Alaska Native populations with substance abuse problems as in the general population. Common co-morbid conditions are major depressive disorder, bipolar I and bipolar II disorders, dysthymia, anxiety disorders, including post traumatic stress disorder, and schizophrenia (Barron et al., 1999).

Epidemiological and ethnographic studies of Native Americans continue to emphasize patterns of excessive alcohol use and its related destruction to indigenous individuals, their families, and their communities. Many American Indians abstain completely from the use of alcohol; but those who do drink tend to have more problems associated with their drinking than do non-American Indian drinkers. Studies have shown that Native Americans have less of the enzyme alcohol dehydrogenase (ADH). Therefore, they are unable to metabolize alcohol as efficiently as individuals with more ADH, possibly causing them to become intoxicated faster and experience liver problems sooner (www.montana.edu, 2006).

American Indian drinkers are more likely to drink large quantities, experience blackouts, and suffer from substance use disorders than non-American Indian drinkers. Research suggests that one-quarter to one-third of adult American Indians have had a substance use problem in the past year, and as many as three-quarters of males and 40% of females may experience a substance use disorder in their lifetime. These prevalence rates are approximately three times higher than that of the general adult population as found in national epidemiological studies. On average, American Indians/Alaska Natives are five times more likely to die of alcohol-related causes than are whites. (Kessler et al., 1994, and Regier et al., 1988, as cited in Herman-Stahl et al. 2003). Tribal Nations with the highest level of education and household income have the lowest levels of problem alcohol and drug use. Educational attainment and income are significantly associated with substance abuse problems even after controlling for gender, age, and tribal affiliation.

There appears to be differences in substance abuse and treatment seeking behavior by tribe. Substance abuse may be affected by several contextual or cultural characteristics such as the historical context of the introduction of alcohol, tribal history of political and economic oppression, adherence to traditional culture, as well as community attitudes and policies regarding alcohol (Beauvais, 1998, and Weisner et al., 1984, as cited in Herman-Stahl & Chong, 2002). Many American Indians strongly believe that their abrupt detachment from traditional culture is at the root of their abuse of alcohol (Beauvais, 1998 and May, 1992, as cited in Herman-Stahl, et al., 2003). Losing touch with important values, rituals, and traditions may have alienated Native Americans from their long-established coping strategies and behavioral standards (LaFromboise, 1988 and May, 1982, as cited in Herman-Stahl, et al., 2003).

Cultural Competencies Needed for Providing Effective Mental Health Services for American Indians/Alaskan Natives

Therapists may incorrectly assume that American culture is so pervasive that there is no need to understand Native culture in order to treat American Indians/Alaskan Natives. This naïve assumption neglects the fact that Native culture is as potent a force in their lives as the broader American culture and it is precisely the clashes and disconnects between the two cultures that often provoke the most stress. Biculturalism is almost always a significant therapeutic concern. Also, there are cross-cultural barriers to receiving and participating in treatment among nearly all Native communities.

First of all, traditional measures of mental disorders were designed for use in the majority population. Assessment measures, which were developed with and for European Americans, generally fail to take into account that American Indians and other ethnic groups conceptualize health, well being and feelings in different ways. Therefore, their expressed symptoms often differ. For example, words such as depressed and anxious do not exist in some American Indian and Alaskan Native languages. Feelings of guilt and shame are often expressed and understood in diff e rent ways than they are within Western culture (Manson et al. 1985, as cited in Thrane et al., 2004) and some tribes discourage expressions of deep sadness and sorrow (Miller & Schoenfeld, 1971, as cited in Thrane et al., 2004). Somatic complaints and emotional distress are not well differentiated from each other in this population. It is a significant challenge to elicit, understand, and incorporate American Indian/Alaskan Native expressions of distress within the assessment and treatment framework of the DSM-IV (DHHS, 2001). These cultural differences are magnified because American Indians in the US alone speak over 200 distinct languages (Fleming, 1992, and LaFromboise, 1988, as cited in Thrane et al., 2004).

Next, the availability of mental health services is severely limited by the isolated, rural locations of many American Indian/Alaska Native communities. These locations present special challenges for outreach and provision of care to these communities. In addition, insurance coverage is low within this population. Within the Native population, 20 percent of individuals lack health insurance, compared to 14 percent of whites (DHHS, 2001). As victims of extreme poverty, it is unlikely that they would seek out any services for which they would be expected to pay. Other barriers to providing and accessing services are lack of American Indian providers, lack of financial resources, and a lack of trust for non-American Indian practitioners. Past governmental policies regarding this population have led to mistrust of many government services or services provided by white practitioners. Furthermore, practitioners may be attempting to treat social and political problems as mental health problems; in which case, the situation, not the individual, needs management (Barron et al., 1999).

American Indians often have cultural, religious, and social values and beliefs that differ greatly from the general population. Their culture is poorly understood and different from that of the general population. These differences create conflict as they struggle to meet the expectations of their families/communities, as well as the demands of the majority culture (Barron et al., 1999). Also, clients may feel uncomfortable and misunderstood by any practitioner who is not American Indian; while Western practitioners may feel ill-equipped to work with these clients within the context of a traditional psychotherapeutic model.

Several research studies suggest that to the extent to which ethnic minorities identify with and participate in their own traditional culture(s) is important for psychological well-being. Cultural identification has begun to receive attention in research on substance use and abuse among ethnic minority adolescents and adults, including American Indians (De La Rosa et al., 2000, as cited in Herman-Stahl et al., 2003). Research findings from Herman-Stahl et al. (2003) indicate that cultural orientation does have relevance for American Indian substance use behavior. Low orientation to American Indian culture and biculturalism were associated with higher levels of multiple types of substance misuse including heavy and extended drinking, illicit drug use, poly-drug use, and alcohol abuse and dependence. Furthermore, enculturation is defined as the process by which individuals identify with their own minority culture (Herman-Stahl et al., 2003). Enculturation has been found to reduce adolescents’ participation in delinquent activities, such as drug and alcohol use and early sexuality. Enculturated youth with high levels of self-esteem appear to be buffered from alcohol and drug use (Thrane et al., 2004).

Clinicians must understand the cultural context of American Indian clients in order to accurately assess the causes and consequences of behavior within this population. In order to be effective, mental health providers must be culturally competent and sensitive to traditional values, taking into account the importance of definitions and expectations of behavior within the community.
It is critical for clinicians to recognize the effects of complex and prolonged trauma on psychological functioning in order to understand the symptoms and issues faced by Native individuals, families and communities (Ford, 1999, Ford & Kidd, 1998, and Zlotnick et al., 1996, as cited in Wardman & Quantz, 2005). Postcolonial trauma is associated with a high level of posttraumatic stress within these communities, and several research studies suggest that Native individuals suffer with secondary consequences similar to those exhibited by Jewish Holocaust and Khmer Rouge survivors. Furthermore, researchers have observed high rates of psychiatric disorders, substance abuse and social problems, including violence, within Native communities.

Culturally Sensitive Psychotherapeutic Strategies for American Indians/Alaskan Natives

Approximately 101 American Indian/Alaskan Native mental health professionals are available per 100,000 individuals from this ethnic group, compared to 173 per 100,000 for whites. In 1996, only 29 psychiatrists in the US were of American Indian/Alaskan Native heritage (DHHS, 2001). Furthermore, many theorists question the use of traditional psychotherapy with indigenous populations because western psycho-therapies are based on values, symbolic systems, and interactional styles which are culturally irrelevant to Native people seeking relief from psychological distress. Some theorists advocate that Native patients be referred to traditional healers who perform a more culturally based form of psychotherapy (Torrey, 1986, as cited in Mohatt & Varvin, 1998). The research available on mental health and substance abuse treatment with Native populations suggests that culturally diverse treatments that include traditional forms of healing and use ethnically matched counselors are most effective. The literature advocates for cultural adaptation of psychotherapy and close, complementary work between Native healers and Euro-American clinicians in every phase of treatment (Mohatt & Varvin, 1998). Western clinicians treating clients who live on the reservation must be willing to go to the reservation to conduct psychotherapy as a way of accessing the client, making him or her feel most comfortable, and as a means of invoking family participation in treatment (Barron et al., 1999). Regardless of one’s knowledge of Native culture and healing practices, Western practitioners must be respectful and cooperative with Native healers. Family members should be included in the therapy sessions whenever possible. These modifications will mimic the rules for social interaction within the community and give the practitioner more credibility (Mohatt & Varvin, 1998). Native individuals living in cities are often hesitant to share the ways of their tribes unless they are specifically invited to by the therapist because their biculturalism is invisible to the therapist. Neither language nor dress nor profession can clue the therapist into the fact that Native culture is essential to the client’s world view. Effective therapists will try to weave an intervention that maximizes the relief factors to be found in both cultures. But to do this, they must first learn, from the client, the important rituals and solutions to distress used by the tribe.

Complimentary Systems

Traditional healing practices and spirituality figure prominently in the lives of American Indians/Alaska Natives and should be seen as complementing, rather than competing, with Western medicine. Traditional healing is used by a majority of American Indian/Alaska Natives (DHHS, 2001). While both systems can compliment each other, there are differences that can be the source of conflict. Goals and explanatory models for etiology and treatment vary (Mohatt & Varvin, 1998). Uncommon behaviors, such as psychotic symptoms, are often explained as having spiritual causes and traditional healing is intended to foster a new relationship between body and spirit (Mohatt & Varvin, 1998).

For centuries, tribes have utilized traditional healing ceremonies which have a natural therapeutic and cathartic effect. For example, the inipi, a healing ceremony, is considered to be physically, emotionally, and spiritually healing. Participants are able to share their pain and pray for the good of others, as well as their own individual healing. Many individuals maintain sobriety only after they begin or resume regular involvement in traditional spiritual rituals (Brave Heart & DeBruyn, 1998). Deepening involvement in traditional American Indian rituals and practices and returning to more traditional beliefs may provide this population with important coping resources for managing stress. Furthermore, the incorporation of traditional healing methods, such as talking circles and sweat lodges, may enhance the effectiveness of mental health/substance abuse treatment programs. Moreover, an emphasis on positive ethnic identity development and cultural preservation may be important components for mental health/substance abuse prevention and treatment programs (Herman-Stahl et al., 2003).

Traditional methods of healing mental and physical health disorders include talking circles, sweat lodges (oinikage), healing ceremonies (wapiya lowanpi), and the use of medicine men. Talking circles are very much like group therapy or support group settings. Sometimes a talking stick is used during the circle and only the person holding the stick is allowed to speak. Others must be quiet, listen and make eye contact with the speaker as a sign of respect. Sweat lodges are similar to saunas. They are designed to detoxify, de-stress, and revitalize the body while bringing an individual in closer communion with the earth. The lodge symbolizes the womb of Mother Earth, and it is a low, domed structure made of wood or frame covered with rugs or tarp. The heat inside a sweat lodge can reach 90 degrees as fire-heated rocks are placed in a depression near the entrance. As the air heats up, participants lie down on the ground and breathe deeply in order to commune with the four elements: Air, Water, Earth, and Fire (Dailyom, 2004).

A medicine man may treat a client by performing a healing ceremony and supporting the client during a sweat lodge while stating that the spirits working with him would strengthen the client. In the healing ceremonies, everyone present is to participate solely for the purpose of helping the client. Friends and relatives offer prayers, words of encouragement, and commitments to helping the client to be successful within the community. Native clients often find the ceremonies and practices helpful to reestablishing emotional bonds with others. The support of the community strengthens the individual’s sense of identity while fostering a greater sense of respect for the community. These social support networks are critical in helping clients be successful while managing a mental illness and/or substance abuse disorder. Furthermore, healing ceremonies demonstrate to family members and friends their important role in helping individuals within the community. The family can be used to communicate progress and to monitor changes and notify Western practitioners or traditional healers if symptoms persist or worsen (Mohatt & Varvin, 1998).

One respected and accepted treatment approach developed by American Indian/Alaska Native communities for use with Native peoples is the Medicine Wheel. The Medicine Wheel model differs from community to community and may be unfamiliar to some American Indian/Alaska Native communities. It is a useful tool in that it helps attend to the individual in a holistic manner with a focus on balance between the spiritual, physical, mental/emotional, and social/cultural elements of the whole person. It can be used as a strength/needs list, a goal list, and a treatment plan all in one. The Medicine Wheel is a simple, elegant circle with a cross bar in the center and may be enhanced to fit the taste of the user. At each of the four directions—north, south, east, and west—one is positioned. Clinicians can have clients graphically demonstrate on the Medicine Wheel the extent of their wellness in each area by marking their status from the inner circle to the outer rim in each of the four directions. The Medicine Wheel allows for individual interpretation, which increases client’s participation in assessment, as well as in planning and monitoring their treatment. The Medicine Wheel provides a visual picture of an individual’s state of wellness and reminds the clinician and the client to incorporate the whole person in the treatment process (Gray & Nye, 2001).

Psychotherapy can assist an American Indian client if it serves his/her personal goals and is conducted in a way that fits the social interactional cultural rules, especially the cultural norm of family involvement. Also, therapy can serve as a compliment to indigenous healing provided that the client is motivated to use both systems and the principal practitioners are committed to working together in a complimentary manner (Mohatt & Varvin, 1998).
Effective provision of mental health services can prove to be a daunting task when working with a previously underserved cultural group. However, clinicians can both empower and assist clients in any cultural group by acknowledging the salience of historical and socio-cultural factors which impact mental health functioning. Mental health providers facilitate change by incorporating complementary indigenous cultural practices with traditional clinical training. By developing culturally-relevant strategies for working with diverse populations, clinicians are prepared to undertake service provision in a professional, competent manner.

Provider Competencies*

TRAINING NEEDED:
1. Specialized assessment and service delivery techniques.
2. Recognition and utilization of the unique features of monocultural (“traditional”), acculturating (“transitional”), and multicultural and multiracial consumers and families.
3. Appreciation of culturally-based traditional healing systems and traditions in the Native American communities served.
4. Specialized engagement and therapeutic alliance building techniques, as well as culturally acceptable and therapeutic boundary setting.
5. Interdisciplinary team interaction and functioning to promote effective care.
6. Use of client’s preferred language in the treatment process.
7. Treatment of Native American sexual minorities, particularly the stress of “triple stigma”(mental illness, ethnic, and sexual).
8. Documentation and/or communication of specialized assessment and service delivery methods such that staff who are not culturally competent will be able to benefit from it.

KNOWLEDGE NEEDED:
9. Differences in symptom expression, symptom language, and symptomatic patterns in Native Americans with mental illness/emotional disturbance.
10. Differences in thresholds of individual and social distress in Native American consumers and tolerance of symptomotology by their natural support systems. This would include the individual, the family, their informal and formal social context.
11. Differences in the attribution of mental illness and issues around stigma specific to Native American cultures.
12. Differences in the acceptability and effectiveness of different treatment modalities in Native American populations.
13. Culture-bound syndromes associated with the Native American populations and subcultures being served.
14. Use of formally trained interpreters by clinicians who are not bilingual.
15. Effects of class and ethnicity on behavior, attitudes, and values.
16. Help seeking behaviors of Native Americans.
17. Self treatment behaviors of Native American which includes the abuse of alcohol and other substances as ‘medication.’
18. Role and manifestation of spirituality, traditionality, and faith in Native American families.
19. Role of verbal and nonverbal language, speech patterns, and communication styles in Native American communities.
20. Effects of human service policies on Native American and reduction of barriers through informed participation in systems change efforts.
21. Resources (agencies, persons, informal helping networks, research) that can be utilized on behalf of Native American consumers and communities.
22. Role and types of power relationships within the community, agency, or institution and their impact on Native American consumers.
23. Recognition of the ways that mainstream professional values may conflict with or be responsible to the needs of Native American consumers.

UNDERSTANDING OF:
24. Historical factors which affect the mental health of Native Americans, such as racism, forced historical migration and current migration patterns.
25. Factors which define cultural differences between different Native American nations and communities, including differences related to history, traditions, values, belief systems, acculturation and migration history, reasons for immigration, and dialect and language fluency. This is particularly important for providers who serve multiple tribes.
26. Particular psychosocial stressors and traumas relevant for Native American consumers. These include war, trauma, migration, unique aspects of cultural survival and maintenance, and socioeconomic status.
27. Cultural variations within Native nations and communities.
28. Native consumers within a family life cycle and intergenerational conceptual framework in addition to individual identity development in relation to family and cultural developmental frameworks.
29. Differences between “culturally acceptable” behavior or psychopathological characteristics of Native Americans.
30. Indigenous healing practices and the role of belief systems (religion and spirituality) in the treatment of Native Americans.
31. A community-based system of mental health care for Native Americans, including appropriate, culturally relevant components and characteristics.
32. Public administrative issues in developing, implementing and evaluating programs for Native Americans.
33. Dynamics of language use and conceptual frameworks among monolingual and bilingual consumers.
34. The effects of the acculturation process on Native Americans.

SKILLS TO:
35. Interview and assess minority clients and families based on psych/social/bio/cultural/political/spiritual/ environmental/economic models.
36. Communicate and listen effectively across cultures.
37. Assess Native American consumers with an understanding of cultural differences in psychopathology.
38. Formulate culturally competent service plans (case management and treatment) that are appropriate for the client and the family’s concept of mental illness.
39. Create and implement multidisciplinary service plan (case management and treatment) include culture, family and community.
40. Utilize culturally appropriate community resources (i.e. family, clans, societies, church, community members and other groups).
41. Provide psychotherapeutic and psychopharmacological interventions, with an understanding of the cultural differences in treatment expectations and biological response to medications.
42. Recognize the limitations of psychological tests and testing procedures when used with Native American consumers.
43. When conducting research, ensure that it is culturally sensitive.
44. Provide education and advocacy interventions which promote consumer and family voice and ownership in shaping the service delivery system.
45. When feasible, use client’s language to elicit the range and nuances of emotions, feelings, dynamics, etc.
46. Know when and how to use interpreters; understand the limitations of using interpreters. Need to be aware of how interpreters (knowingly or unknowingly) may censor and modify information during the process of interpretation.
47. Learn the particulars of social conventions (from engaging protocols to termination rituals) within Native cultures.
48. Cultural competence is a learning process, not a product. Be open to continually learn the cultures of Native American consumers and families through varied and multiple techniques (conferences, visiting in community, reading books, hanging out, attending community forums, etc.).
49. Be aware of racial and ethnic differences and know when to respond to culturally-based cues.
50. Assess the meaning race and ethnicity has for individual consumers.
51. Differentiate between the symptoms of intrapsychic stress and stress arising from the social structure.
52. Work toward empowerment of consumers and minority communities.
53. Able to use community resources on behalf of Native American consumers and their communities.
54. Able to use agency resources on behalf of Native American consumers and their communities.
55. Recognize and combat racism, racial stereotypes, and myths in individuals and in institutions.
56. Evaluate new techniques, exemplary practices, research, and knowledge as to their validity and applicability in working with Native Americans.

ATTITUDES:
57. Personal qualities that reflect “genuineness, accurate empathy, nonpossessive warmth” (Traux and Mitchell) and a capacity to respond flexibly to a range of possible solutions.
58. Acceptance of ethnic differences between people, and how these affect the treatment process.
59. A willingness to work with clients of various ethnic minority groups.
60. Respect for the immigrant, migration, colonization, dissolution of culture experience.
* This panel was sponsored by the Western Interstate Commission for Higher Education (WICHE) Mental Health Program and funded by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration.

Author

Lateffa Carter King, MSW, is a 3rd year Clinical Psychology student at Howard University in Washington, D.C. and a National Register trainee. Mrs. King received her MSW from Howard University School of Social Work in 1998. She earned a BA as an Echols Scholar at the University of Virginia, with a double-major in Psychology and African/Afro-American Studies. Mrs. King resides in Alexandria, Virginia, with her husband and three children.

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