Stringer, H. (2023, October 1). The healing power of Native American culture is inspiring psychologists to embrace cultural humility. Monitor on Psychology, 54(7). https://www.apa.org/monitor/2023/10/healing-tribal-communities-native-americans
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The COVID-19 pandemic and the Black Lives Matter movement have raised consciousness about the country’s persistent health inequities, but one group is often overlooked in efforts to reduce these disparities: American Indian and Alaska Native people. Data reveal troubling realities about the long-standing and escalating mental health conditions affecting the 3.7 million people in this population.
Alcohol-induced deaths were highest among American Indian and Alaska Native people at 172 per 100,000, followed by Latinx people at 26.6, Whites at 25.8, and Blacks at 18.4, according to national data from 2016. These deaths could be caused by alcoholic liver disease, mental and behavioral disorders due to alcohol use, degeneration of the nervous system, or other conditions related to alcohol consumption (Spillane, S. et al., JAMA Network Open, Vol. 3. No. 2, 2020). The largest escalations in suicide rates from 1999 to 2017 occurred in American Indian and Alaska Native women and men, with increases of 139% and 71%, respectively. By comparison, the increases for White women and men were 68% and 40%, and even less for other racial and ethnic groups (Curtin, S. C., & Hedegaard, H., Health E-Stats, 2019).
COVID-19 also disproportionately affected tribal communities. They experienced the largest drop in life expectancy of any racial and ethnic group in the United States during the pandemic. In 2021, the life expectancy for American Indian and Alaska Native people was 65.2 years—equal to the life expectancy of the total U.S. population in 1944 (Arias, E., et al., Vital Statistics Rapid Release, No. 23, 2022). The average life expectancy was 70.8 for Blacks, 76.4 for Whites, and 77.7 for Latinx people in 2021. Despite high rates of health conditions, the Indian Health Service (IHS)—a federal program that provides care to more than 2.5 million American Indian and Alaska Native people—has far less funding per patient than Medicare, Medicaid, or the Veterans Health Administration (VA). IHS per capita spending in 2017 was $4,078 for IHS patients, compared with $8,109 for Medicaid patients and more than $10,000 for Medicare and VA patients (Indian Health Service: Spending Levels and Characteristics of IHS and Three Other Federal Health Care Programs, U.S. Government Accountability Office, 2018).
Although these health disparities may seem intractable, Native American psychologists suggest that progress has been slow in part because the mental health profession needs to embrace a new paradigm to better serve American Indian and Alaska Native people. “The traditional understanding of mental health issues and the models for treating them are still rooted in a Western perspective,” said Art Blume, PhD, a clinical psychology professor at Washington State University who is Cherokee and Choctaw. “In psychology, we focus on treating the individual and promoting autonomy as a marker for health and well-being, but this is not necessarily the worldview of Indigenous people.” Traditionally, many tribes have viewed the world as an interdependent system in which the cosmos, the natural environment, and the community are connected to wellness, Blume added.
Rather than adapting empirically validated treatments from mainstream psychology, Blume is among a cadre of psychologists who are calling for the development of innovative treatment approaches based on American Indian and Alaska Native values and worldviews. As a start, practitioners and researchers must embrace cultural humility and a willingness to learn how the history of subjugation, oppression, and dispossession has affected tribal communities, said Harvard University’s Joseph Gone, PhD, a professor of anthropology and of global health and social medicine who is also past-president of the Society of Indian Psychologists. “Our way of life was considered hopelessly backwards and savage, and we were expected to become farmers and ranchers and learn reading, writing, and arithmetic,” said Gone, who is a member of the Aaniiih-Gros Ventre Tribal Nation of Montana. “The deep damage from the loss of identity contributed to postcolonial disorders such as suicide, trauma, and addiction.”
Mental health professionals can begin to equip themselves to foster healing in Native American populations by understanding the history of colonialism, learning about the values and traditions of tribal communities, and incorporating spirituality and other sources of strength into treatment. There are 574 federally recognized American Indian and Alaska Native tribes in the United States, and psychologists should be aware that the strategies vary within each community because tribes differ in their beliefs (U.S. Department of the Interior, Indian Affairs, 2022).
“By understanding that what we have learned in school is quite limited in helping these communities, we can begin to see how much they can teach us,” Blume said. “We can learn Indigenous wisdom and explore the strengths that helped them overcome major challenges in history.”
To initiate the process of reconciliation and healing, APA formed an Indigenous Apology Work Group in 2020. The apology, which was approved by the Council of Representatives in February 2023, acknowledges the history of maltreatment, including “destructive harms and forced actions, such as sterilizations, relocations, culture-negating boarding schools, adoptions and removal of Native children from their families and culture and adoption by non-Native parents, intentional infliction of smallpox and introduction of alcohol, termination of sovereign tribes.” The apology also lists psychology’s specific harms. For example, “psychologists provided ideological support for and failed to speak out against the colonial framework of the boarding and day school systems for First Peoples of the Americas.” The work group also created a list of 46 recommendations, such as honoring Native understandings and practices associated with common psychological concepts and supporting the development of assessment tools and interventions by Indigenous psychologists.
In 2021, APA became a liaison member to the Committee on Native American Child Health (CONACH), an American Academy of Pediatrics initiative focused on issues facing American Indian and Alaska Native children. Stephen Gillaspy, PhD, senior director of health and health care financing at APA, recruited four psychologists in 2022 to participate in the committee’s consultation site visits in IHS areas. The CONACH team interacts with frontline health care providers to learn about the needs of each community and innovative models of care, which inform the organization’s advocacy priorities.
Psychologists who work with American Indian and Alaska Native people are slowly pioneering paths that can promote healing. Iva GreyWolf, PhD, who is Assiniboine and Anishinabe, has spent more than 3 decades immersing herself in remote Indigenous communities in Alaska and Montana, and much of her work took place in informal settings rather than in an office. Gatherings are common in these communities, and she would volunteer to help with dishes, serve food, or do other tasks. “I joined them in senior centers, berry picking, and beading, and in those contexts, people gained trust and became comfortable talking about their concerns and struggles,” said GreyWolf.
After confiding in her, individuals were sometimes interested in meeting in her office. But the traditional financial penalties for missing appointments did not apply because GreyWolf understood the obstacles people faced in terms of transportation, funds, and weather. She also learned that humor was an integral part of the culture that had helped people survive and could also reduce barriers. “Learning to laugh at myself when I made a mistake was important,” she said. When she and her husband sat together at a community potluck, some members of a tribe joked about asking her to bring a pie to the next gathering as a fine for sitting with a spouse at a gathering. She learned that the fine was a jovial way of letting her know that it was seen as possessive, and the tribe valued mixing with other members during events.
Their deep commitment to family was sometimes a challenge for Native American students during the COVID-19 pandemic, said Angela Enno, PhD, director of training, programming, and outreach at the University of Utah’s University Counseling Center. During the pandemic, she worked as a therapist at Northern Arizona University and saw many American Indian students who were expected to return to their tribal communities for months at a time to care for family members who were sick. She advocated for these students when professors were hesitant to make allowances for late assignments or missed exams. “These students lacked Internet access, and they were grieving the loss of older relatives who had been versed in the teachings, history, language, and identity of the tribe,” she said.
Although family responsibilities may have conflicted with the demands of school, the focus on collectivism also had advantages for Native American young people who returned to intergenerational households during the pandemic. Studies suggest that people 65 and older were more resilient psychologically than younger people during the pandemic, with lower rates of anxiety disorder, depressive disorder, or trauma or stress-related disorders than young age groups (Vahia, I. V., et al., JAMA, Vol. 324, No. 22, 2020).
“We have so much data showing that access to culture improves mental health for Native Americans, and access to culture comes from the elders,” said Enno. When students struggled with depression and other mental health conditions, the wisdom of elders included staying busy by getting up early, chopping wood, caring for the animals, and praying, said Enno.
Although Native Americans may share certain values, the customs and beliefs in each tribe can vary. For this reason, Enno allows time for cultural sharing at the outset of the first session with these clients rather than starting with a series of questions. “I give them a chance to ask about me and to talk about what their tribal identity means to them,” said Enno, who is a first-degree descendent of the Turtle Mountain Chippewa in North Dakota. This means her father is a tribal member and she is not. “I explore the extent to which they want to bring their Indigenous perspective into therapy.”
During the pandemic, she also learned to be flexible when working with Native Americans who were experiencing grief. “Psychologists usually tend to encourage clients to talk about the loved one who died and to express emotions. But in some tribes, there is a circumscribed time of talking and crying, and then you are expected to move on for cultural and spiritual reasons that can vary tribe to tribe,” said Enno. Some of her clients wanted to learn strategies for containing emotions and finding joy again because they wanted to honor their Native traditions related to grieving.
The role of men and women may also differ in tribes, said Melissa Tehee, JD, PhD, an associate professor of psychology at Utah State University and a member of the Cherokee Nation. She is from a matrilineal tribe in which women are outspoken and traditionally a husband moved in with the wife’s family after marriage. The meanings of different animals also vary depending on someone’s tribal affiliation. In one slide presentation, Tehee had planned to include an image of an owl, but she decided against it after discovering that this animal could signify danger for members of certain tribes. Now she checks in about tribal affiliations and beliefs before meetings or trainings to learn about the meaning of certain animals or other spiritual references she plans to include.
Learning about the values, spirituality, and communication styles in Native American communities helps providers connect with patients and avoid misdiagnosing them. Interpersonal behavior that is culturally appropriate can sometimes be viewed as symptoms of autism spectrum disorder, said B. J. Boyd, PhD, a senior psychologist for the Chickasaw Nation in Oklahoma and a member of the Cherokee Nation. “Native American children who avoid eye contact or take longer to answer a question may be acting appropriately, but this can be misconstrued as signs of autism,” Boyd said. “In Western culture, children are usually expected to answer promptly to let adults know they have been heard.” Boyd ensures each patient is evaluated in a culturally sensitive manner.
He has also seen how non-Native health care providers assume patients are exhibiting symptoms of mental illness or drug problems when in fact the patients are discussing their mental health struggles in spiritual terms. Boyd worked with one Native American patient who was suffering from anxiety, and the man shared with providers that the birds and squirrels in his yard helped him understand his illness. “I had to intervene and stop providers from diagnosing him with schizophrenia because he was simply finding meaning and comfort to help him process his illness,” said Boyd.
As psychologists seek to better serve Native Americans, changes in the approach to care have the potential to improve the well-being of people from a wide range of racial and ethnic groups. Tehee’s research team at Utah State University recently partnered with a local elementary school to help students learn more about Native American culture, and the year-long project included exercises that helped students share about their own culture. “We found that over time, learning about other cultures increased the students’ connections to their own culture,” Tehee said. The students also increased their level of cultural empathy, or the ability to understand the experiences of people from a different culture (Litts, B. K., et al., International Society of the Learning Sciences, 2020).
By incorporating discussions about culture earlier in education, Tehee hopes to develop a generation of culturally competent citizens who are more curious about their own and others’ cultures. “This opens up space for all the students to experience a sense of belonging,” she said. “If they are feeling more connected to others, they will be more likely to let someone know if they are struggling rather than remaining silent.” These conversations about culture can take place in classrooms, research labs, clinical settings, and social gatherings, and it is critical to start by “recognizing your limitations in understanding,” said Gone. He encourages psychologists to be open to treating clients from any background and to be willing to openly share their limited ability to serve people from different cultural affiliations.
“By doing that, we are beginning to rehabilitate the deep sense of inferiority and shame among Native Americans that resulted from colonial subjugation as we form new relationships with marginalized communities and individuals.”
