Joseph P. Gone

Mental Health Services for Native Americans in the 21st Century United States

As the population of American Indians and Alaska Natives continues to expand in the 21st century United States, an increasing number of professional psychologists will be called upon to provide culturally appropriate mental health services for Native American people and their communities. This article provides a general overview of contemporary tribal America before describing the legal, political, and institutional contexts for mental health service delivery administered through the federally sponsored Indian Health Service. Recommendations for mental health professionals who desire to avoid a subtle but profound Western cultural proselytization in their therapeutic service to Native clients and their communities are presented. It is the policy of this Nation, in fulfillment of its special responsibilities and legal obligation to the American Indian people, to meet the national goal of providing the highest possible health status to Indians and to provide existing Indian health services with all the resources necessary to effect that policy. (Pub. L. No. 94-437, §3a)

Rethinking historical trauma.

Recent years have seen the rise of historical trauma as a construct to describe the impact of colonization, cultural suppression, and historical oppression of Indigenous peoples in North America (e.g., Native Americans in the United States, Aboriginal peoples in Canada). The discourses of psychiatry and psychology contribute to the conflation of disparate forms of violence by emphasizing presumptively universal aspects of trauma response. Many proponents of this construct have made explicit analogies to the Holocaust as a way to understand the transgenerational effects of genocide. However, the social, cultural, and psychological contexts of the Holocaust and of post-colonial Indigenous “survivance” differ in many striking ways. Indeed, the comparison suggests that the persistent suffering of Indigenous peoples in the Americas reflects not so much past trauma as ongoing structural violence. The comparative study of genocide and other forms of massive, organized violence can do much to illuminate both common mechanisms and distinctive features, and trace the looping effects from political processes to individual experience and back again. The ethics and pragmatics of individual and collective healing, restitution, resilience, and recovery can be understood in terms of the self-vindicating loops between politics, structural violence, public discourse, and embodied experience.

Identifying effective mental health interventions for American Indians and Alaska Natives: A review of the literature.

The pursuit of evidence-based practice (EBP) within the mental health professions has contributed to efficacious clinical intervention for individuals struggling with mental health problems. Within the context of the EBP movement, this article reviews the treatment outcome literature for mental health interventions directed specifically toward American Indians and Alaska Natives experiencing psychological distress. Fifty-six articles and chapters pertaining to the treatment of Native Americans with mental health problems were identified, though the vast majority of these did not systematically assess outcomes of specified treatments for Native American clients under scientifically controlled conditions. Of just nine studies assessing intervention outcomes, only two were controlled studies with adequate sample sizes and interpretable results relative to the identification of EBP among American Indians and Alaska Natives. The advantages and limitations of EBP for treatment of Native American mental health problems are discussed.

Redressing First Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment

Indigenous “First Nations” communities have consistently associated their disproportionate rates of psychiatric distress with historical experiences of European colonization. This emphasis on the socio-psychological legacy of colonization within tribal communities has occasioned increasingly widespread consideration of what has been termed historical trauma within First Nations contexts. In contrast to personal experiences of a traumatic nature, the concept of historical trauma calls attention to the complex, collective, cumulative, and intergenerational psychosocial impacts that resulted from the depredations of past colonial subjugation. One oft-cited exemplar of this subjugation—particularly in Canada—is the Indian residential school. Such schools were overtly designed to “kill the Indian and save the man.” This was institutionally achieved by sequestering First Nations children from family and community while forbidding participation in Native cultural practices in order to assimilate them into the lower strata of mainstream society. The case of a residential school “survivor” from an indigenous community treatment program on a Manitoba First Nations reserve is presented to illustrate the significance of participation in traditional cultural practices for therapeutic recovery from historical trauma. An indigenous rationale for the postulated efficacy of “culture as treatment” is explored with attention to plausible therapeutic mechanisms that might account for such recovery. To the degree that a return to indigenous tradition might benefit distressed First Nations clients, redressing the socio-psychological ravages of colonization in this manner seems a promising approach worthy of further research investigation.

Psychotherapy and Traditional Healing for American Indians: Exploring the Prospects for Therapeutic Integration:

Multicultural advocates within professional psychology routinely call for “culturally competent” counseling interventions. Such advocates frequently cite and celebrate traditional healing practices as an important resource for developing novel integrative forms of psychotherapy that are distinctively tailored for diverse populations. Despite this interest, substantive descriptions of specific forms of traditional healing vis-à-vis psychotherapy have appeared infrequently in the psychology literature. This article explores the prospects for therapeutic integration between American Indian traditional healing and contemporary psychotherapy. Systematic elucidation of historical Gros Ventre healing tradition and Eduardo Duran’s (2006) culture-specific psychotherapy for American Indians affords nuanced comparison of distinctive therapeutic paradigms. Such comparison reveals significant convergences as well as divergences between these therapeutic traditions, rendering integration efforts and their evaluation extremely complex. Multicultural professional psychology would benefit from collaborative efforts undertaken with community partners, as interventions developed in this manner are most likely to effectively integrate non-Western healing traditions and modern psychotherapy.

Reviewing Suicide in Native American Communities: Situating Risk and Protective Factors within a Transactional–Ecological Framework

The alarming prevalence of suicidal behaviors in Native American communities remains a major concern in the 21st-century United States. Recent reviews have demonstrated that prevention programs and intervention efforts using transactional–ecological models have effectively reduced suicidal behaviors in the American Indian and Alaska Native populations sampled. As a result, this article adopts a transactional–ecological framework for conceptualizing suicidality and identifying points of intervention. Drawing on the most current empirical reports, the epidemiology of Native American suicidal behaviors is reviewed, while situating risk and protective factors within a biopsychosocial framework. Opportunities for intervention are discussed with a focus on the interactions between individuals and their environments, and the antecedent conditions leading to zones of heightened suicide risk.

Culturally Responsive Suicide Prevention in Indigenous Communities: Unexamined Assumptions and New Possibilities

Indigenous communities have significantly higher rates of suicide than non-Native communities in North America. Prevention and intervention efforts have failed to redress this disparity. One explanation is that these efforts are culturally incongruent for Native communities. Four prevalent assumptions that underpin professional suicide prevention may conflict with local indigenous understandings about suicide. Our experiences in indigenous communities led us to question assumptions that are routinely endorsed and promoted in suicide prevention programs and interventions. By raising questions about the universal relevance of these assumptions, we hope to stimulate exchange and inquiry into the character of this devastating public health challenge and to aid the development of culturally appropriate interventions in cross-cultural contexts.

The Red Road to Wellness: Cultural Reclamation in a Native First Nations Community Treatment Center

This article explores how Native American cultural practices were incorporated into the therapeutic activities of a community-controlled substance abuse treatment center on a “First Nations” reserve in the Canadian north. Analysis of open-ended interviews with nineteen staff and clients—as contextualized by participant observation, program records, and existing ethnographic resources—yielded insights concerning local therapeutic practice with outpatients and other community members. Specifically, program staff adopted and promoted a diverse array of both western and Aboriginal approaches that were formally integrated with reference to the Aboriginal symbol of the medicine wheel. Although incorporations of indigenous culture marked Lodge programs as distinctively Aboriginal in character, the subtle but profound influence of western “therapy culture” was centrally evident in healing activities as well. Nuanced explication of these activities illustrated four contributions of cultural analysis for community psychology.

Introduction: Mental health discourse as western cultural proselytization

In the wake of European settler-colonialism, the indigenous peoples of North America still contend with the social and psychological sequelae of cultural devastation, forced assimilation, social marginality, enduring discrimination, and material poverty within their respective nation-states. In response to this contemporary legacy of conquest and colonization, a cottage industry devoted to the surveillance and management of the ‘‘mental health’’ problems of Native Americans proliferates in the United States and Canada without abatement. The attention of clinically concerned researchers, practitioners, and policy makers to an indigenous ‘‘patient’’ or ‘‘client’’ base, however, invites critical analysis of the cultural politics of mental health in these contexts. More specifically, the possibility that conventional clinical approaches harbor the ideological danger of implicit Western cultural proselytization has been underappreciated. In this special section of Ethos, three investigators engage the provocative cultural politics of mental health discourse and practice in three diverse Native American communities. Each provides a critical analysis of mental health discourse and practice in their respective research settings, collectively comprising an analytical and political subversion of the potentially totalizing effects of authorized, universalist mental health policy and practice. [mental health, American Indians, psychiatric anthropology, cross-cultural counseling, postcolonialism] Interviewer: Under what circumstances would you take your grandkids, say, into Behavioral Health or Mental Health at [the Indian Health Service clinic]? Native Respondent: I would say that’s kind of like taboo. You know, we don’t do that. We never did do that. . . . I guess it’s like a war, but they’re not using bullets anymore. . . . [Sigh] Like ethnic cleansing, I guess you could say. They want to wipe us out. Wipe the Indian reservations out so they could join the melting pot of the modern White society. And therefore the Indian problem will be gone forever. . . . But they’re using a more shrewder way than the old style of bullets. [Gone in press b:14] At the outset of the 21st century, indigenous communities in North America continue to pursue autonomy and self-determination in the aftermath of centuries of European colonization. The sweeping transformations of Native life and livelihood that resulted from European invasion of the New World have included rampant disease, dislocation, demoralization, and disintegration for indigenous communities, even as many of this continent’s 310 ETHOS ETHOS, Vol. 36, Issue 3, pp. 310–315, ISSN 0091-2131 online ISSN 1548-1352. & 2008 by the American Anthropological Association. All rights reserved. DOI: 10.1111/j.1548-1352.2008.00016.x. First Peoples have met these challenges with creativity, fortitude, resilience, and humor. Nevertheless, alarming numbers of Native Americans still contend with the social and psychological sequelae of marginality, poverty, tragedy, and discrimination within their respective nation-states (Kirmayer et al. 2000; U.S. Department of Health and Human Services 2001). Arising from this historical conjuncture is a cottage industry devoted to the surveillance and management of the ‘‘mental health’’ problems of North America’s indigenous peoples. The attention of clinically concerned researchers, practitioners, and policy makers to an indigenous ‘‘patient’’ or ‘‘client’’ base, however, invites critical analysis of the cultural politics of mental health in Native North America (O’Nell 1989; Waldram 2004). Such politics emerge at the confluence of culture, power, and postcoloniality. Although authoritative definitions of culture remain elusive (Borofsky et al. 2001), shared patterns of activity, interpretation, and interaction persist in most Native North American communities. In regard to cultural processes and practices, Native American societiesFlike most human communitiesFrepresent historically distinctive constituencies whose public, patterned, and intergenerationally reproduced semiotic conventions are both durable and dynamic. Moreover, the cultural processes and practices of these societies differ markedly from those of Europe and the West. In the historical wake of the colonial encounter, however, the nation-states of North America came to dominate many indigenous lives thoroughly and ruthlessly (Stannard 1992). Whether through military conquest, religious repression, reservation captivity, forced assimilation, or resource theft, the exercise of power to contain, to control, or to represent demonstrated Euro–North American cultural dominance over most Native lives (Washburn 1988). Thus, the vast majority of the indigenous communities of North America remain heirs to a shattering European colonialism that waged both material and ideological war on the cultural practices of these societies. Finally, despite a postcolonial shift away from the ideologies of extermination, incorporation, and appropriation, Native communities today remain at the margins of their respective settler societies in terms of opportunity and access to educational, economic, political, and cultural resources (Jaimes 1992). Such marginality serves as the backdrop for the (sometimes-frantic) communal pursuit of viable postcolonial sources of coherence, connectedness, and continuity for grounding personal and collective meaning-making (Gone 1999, 2006a; Gone et al. 1999). Indigenous efforts in this regard have frequently yielded a self-conscious, community-based discourse about ‘‘culture’’ that expresses a commitment to the preservation and revitalization of traditional practices that diverge in important respects from their ‘‘Western’’ counterparts. Not surprisingly, scholarly and community considerations of culture, power, and postcoloniality reveal that indigenous and dominant society cultural differences do not in reality intersect and engage on ‘‘equal footing,’’ but are, instead, subject to negotiation in ideologMENTAL HEALTH IN NATIVE NORTH AMERICA 311

Rethinking cultural competence: Insights from indigenous community treatment settings

Multicultural professional psychologists routinely assert that psychotherapeutic interventions require culturally competent delivery for ethnoracial minority clients to protect the distinctive cultural orientations of these clients. Dominant disciplinary conceptualizations of cultural competence are “kind of person” models that emphasize specialized awareness, knowledge, and skills on the part of the practitioner. Even within psychology, this approach to cultural competence is controversial owing to professional misgivings concerning its culturally essentialist assumptions. Unfortunately, alternative “process-oriented” models of cultural competence emphasize such generic aspects of therapeutic interaction that they remain in danger of losing sight of culture altogether. Thus, for cultural competence to persist as a meaningful construct, an alternative approach that avoids both essentialism and generalism must be recovered. One means to capture this alternative is to shift focus away from culturally competent therapists toward culturally commensurate therapies. Indigenous communities in North America represent interesting sites for exploring this shift, owing to widespread political commitments to Aboriginal cultural reclamation in the context of postcoloniality. Two examples from indigenous communities illustrate a continuum of cultural commensurability that ranges from global psychotherapeutic approaches at one end to local healing traditions at the other. Location of culturally integrative efforts by indigenous communities along this continuum illustrates the possibility for local, agentic, and intentional deconstructions and reconstructions of mental health interventions in a culturally hybrid fashion.