CHAPTER 4

Mental Health Care for American Indians and Alaska Natives

Mental Illness Prevention and Mental Health Promotion

Up to this point, the chapter has focused on the prevalence, risk, assessment, and treatment of mental illness among American Indian and Alaska Native youth and adults. The public health model that guides this Supplement stresses the importance of preventive and promotive interventions as well. Indeed, virtually any serious dialogue at both local and national levels about mental health and well-being among American Indians and Alaska Natives underscores the central place of preventive and promotive efforts in the programmatic landscape (Manson, 1982).

Preventing Mental Illness

Among Indian and Native people, efforts to prevent mental illness have been overshadowed by a much more aggressive agenda in regard to preventing alcohol and drug abuse (May & Moran, 1995). The research literature mirrors a similar emphasis on interventions intended to prevent or ameliorate developmental situations of risk, with special emphasis on family, school, and community (Manson, 1982; Beiser & Manson, 1987; U.S. Congress, 1990).

As discussed earlier, poverty and demoralization combine with rapid cultural change to threaten effective parenting in many Native families. This can lead to increased neglect and abuse and ultimately to the removal of children into foster care and adoption (Piasecki et al., 1989). Poverty, demoralization, and rapid culture change also increase the risk for domestic violence, spousal abuse, and family instability, with their attendant negative mental health effects (Norton & Manson, 1995; Christensen & Manson, 2001). The preventive interventions that have emerged in response to such deleterious circumstances in American Indian communities are particularly creative, in form as well as in reliance upon cultural tradition. One example is the introduction of the indigenous concept of the Whipper Man, a nonparental disciplinarian, into a Northwest tribe’s group home for youth in foster care (Shore & Nicholls, 1975). This unique mechanism of social control, coupled with placement counseling and intensive family outreach, significantly enhanced self-esteem, decreased delinquent behavior, and reduced off-reservation referrals (Shore & Keepers, 1982). Another example is a developmental intervention that targeted Navajo family mental health (Dinges et al., 1974). This effort sought to improve stress resistance in Navajo families whose social survival was threatened and to prepare their children to cope with a rapidly changing world. It focused on culturally relevant developmental tasks and the caregiver-child interactions thought to support or increase mastery of these tasks. Delivered through home visits by Navajo staff, the intervention promoted cultural identification, strengthened family ties, and enhanced child and caregiver self-images (Dinges, 1982).

Fueled by longstanding concern regarding the disruptive nature of boarding schools for the emotional development of Indian youth, early prevention programs focused largely on social and cultural enrichment. The most widely known of these early efforts is the Toyei Model Dormitory Project, which improved the ratio of adult dormitory aides to students, replaced non-Navajo houseparents with tribal members, and trained them to be both caretakers and surrogate parents (Goldstein, 1974). As a result, youth in the Toyei model dormitory showed accelerated intellectual development, better emotional adjustment, and superior performance on psychomotor tests. The promise of this approach was slow to be realized, however, in part because of a change in Federal policy away from boarding school education for American Indians and Alaska Natives, and in part because local control over educational settings in Indian communities was rare until recently (Kleinfeld, 1982). Schoolwide interventions only now are emerging in Native communities, as successful litigation and legislative change in funding mechanisms transfer to tribes the authority to manage health and human services, including education (Dorpat, 1994).

Targeted prevention efforts have flourished in tribal and public schools. Most have centered on alcohol and drug use, but a growing number of programs are being designed and implemented with a specific mental health focus, typically suicide prevention (Manson et al., 1989; Duclos & Manson, 1994; Middlebrook et al., 2001). These preventive interventions take into account culture-specific risk factors: lack of cultural and spiritual development, loss of ethnic identity, cultural confusion, and acculturation. Careful evaluation of their effects, though still the exception, illustrates, as in the case of the Zuni Life Skills Development Curriculum, the significant gains that can accompany such investments (LaFromboise & Howard-Pitney, 1994).

With increasing frequency, entire Indian and Native communities have become both the setting and the agent of change in attempts to ameliorate situations of risk and to prevent mental illness. Among the earliest examples is the Tiospaye Project on the Rosebud Sioux Reservation in South Dakota, which entailed organizing a series of community development activities that were cast as the revitalization of the tiospaye, an expression of traditional Lakota lifestyle based on extended family, shared responsibility, and reciprocity (Mohatt & Blue, 1982). More recent ones include the Blue Bay Healing Project among the Salish-Kootenai of the Flathead Reservation (Fleming, 1994) and the Western Athabaskan “Natural Helpers” Program (Serna et al., 1998). Both of these community-based interventions marshaled local cultural resources consistent with long-held tribal traditions, albeit in quite different ways that reflected their distinct orientations. Other nationwide initiatives, such as those mentioned earlier in this chapter, are likewise deeply steeped in the emphasis on community solutions to community problems.

Promoting Mental Health

Indian and Native people are quick to observe that the prevention of mental illness—with its goals of decreasing risk and increasing protection—is defined by a disease-oriented model of care. Although this approach is valued, professionals are encouraged by Indian and Native people to move beyond the exclusive concern with disease models and the separation of mind, body, and spirit, to consider individual as well as collective strengths and means in the promotion of mental health.

There is less clarity about and little common nomenclature for such strengths, their relationship to mental health, and technologies for promoting them than there is for risk, mental illness, and prevention. Even less data exist upon which to base empirical discussions about tar-gets for promotion and outcomes, but there are relevant intellectual histories that suggest this is no quixotic quest. For example, the contemporary literature on psychological well-being has its roots in past work on dimensions of positive mental health and the related concept of happiness (Jahoda, 1958; Bradburn, 1969), which have evolved into the closely related constructs of competence, self-efficacy, mastery, empowerment, and communal coping (David, 1979; Swift & Levin, 1987; Sternberg & Kolligian, 1990; Bandura, 1991). Clear parallels exist between these ideas and central themes for organizing life in Native communities. Consider, for example, the concept of hozhq in the Navajo worldview:

Kluckhohn identified hozhq as the central idea in Navajo religious thinking. But it is not something that occurs only in ritual song and prayer; it is referred to frequently in everyday speech. A Navajo uses this concept to express his happiness, health, the beauty of his land, and the harmony of his relations with others. It is used in reminding people to be careful and deliberate, and when he says good-bye to someone leaving, he will say hozhqqgo naninaa doo “may you walk or go about according to hozhq.” (Witherspoon, 1977)

Hozhq encompasses the notions of connectedness, reciprocity, balance, and completeness that underpin con-textually oriented views of health and well-being (Stokols, 1991). Although the terms of reference vary, this orientation is commonly held across Indian and Native communities. The American Indian and Alaska Native experience may lead to the rediscovery of the fundamental aspects of psychological and social well-being and the mechanisms for their maintenance.

In this regard, as noted in Chapter 1, recent years have seen the development of sophisticated theoretical formulations of the relationships among spirituality, religion, and health. Most work in this area has focused on populations raised in Judeo-Christian traditions and, consequently, measurement approaches generally remain contained within this cultural horizon (The Fetzer Institute & National Institute on Aging, 1999). American Indian and Alaska Native populations, on the other hand, often participate in very different spiritual and religious traditions, which require expanded notions of spirituality and religious practice (Reichard, 1950; Gill, 1982; Hultkrantz, 1990; Vecsey, 1991 Beauvais, 1992; Harrod, 1995; Tafoya & Roeder, 1995; Csordas, 1999). Especially notable here are the importance in many Native traditions of private religious and spiritual practice, an emphasis on individual vision and revelation, ritual action in a world inhabited by multiple spiritual entities, and complex ceremonies that are explicitly oriented to healing. Moreover, many American Indian and Alaska Native people participate in multiple traditions. Traditional tribal and pan-Indian beliefs and practices continue to be influential, especially in help-seeking (Kim & Kwok, 1998; Csordas, 1999; Buchwald et al., 2000; Gurley et al., 2001). Christian religions are also quite important in many Indian communities (Spangler et al., 1997). There is mounting evidence that many Indian people do not see Christianity and traditional practices as incompatible (Csordas, 1999). This dynamic is probably most evident in the Native American Church (NAC), where Christian and Native beliefs coexist (Aberle, 1966; Pascarosa et al., 1976; Vecsey, 1991).

More explicit attention to the connections between spirituality and mental health in Native communities is especially warranted given the nature and type of problems described previously.