U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Behavioral Health Services for American Indians and Alaska Natives: For Behavioral Health Service Providers, Administrators, and Supervisors [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2018. (Treatment Improvement Protocol (TIP) Series, No. 61.)

Cover of Behavioral Health Services for American Indians and Alaska Natives

Behavioral Health Services for American Indians and Alaska Natives: For Behavioral Health Service Providers, Administrators, and Supervisors [Internet].

Show details

Part 1, Chapter 1

Introduction

This Treatment Improvement Protocol (TIP) is designed to assist you, the provider or program administrator, in working with and providing culturally responsive services to American Indian and Alaska Native clients in behavioral health service settings. This manual is addressed to all kinds of behavioral health service providers—counselors, outreach workers, prevention specialists, healthcare professionals, psychologists, program managers, and administrators—whose work is directly or indirectly concerned with supporting American Indian and Alaska Native clients and communities in recovery from mental illness and substance abuse.

This manual, using guidance from consensus panels, weaves together practice-based experience with available published resources and research relevant to behavioral health in American Indians and Alaska Natives. A group of respected American Indian and Alaska Native behavioral health service providers, clinical directors, researchers, and administrators from across Indian Country formed the clinical- and administrative-focused consensus panels; their contributions shaped the development and content of this TIP.

This TIP begins with a demographic, historical, and cultural overview of American Indians and Alaska Natives, laying the necessary groundwork that supports the dialog, suggestions, and resources that follow. This TIP can serve as a resource to both native and non-native providers in providing culturally appropriate and responsive services. By emphasizing the strengths of native cultures and reinforcing the importance of a holistic perspective in the etiology and treatment of substance use and mental disorders, it will help dispel the myths and stereotypes about American Indians and Alaska Natives.

This TIP Is for You, the Behavioral Health Services Provider

If you want to reflect on your work and enhance your cultural competence in relationships with your American Indian and Alaska Native clients, this TIP is for you. If you are new to working with American Indian and Alaska Native clients, or if you find that your usual approaches to providing treatment services just do not seem to work as well with these clients, you are also the person for whom this TIP has been developed.

You know your work, and you are likely good at it. You may assume that your clients see you as credible because you have earned your position; you have credentials that speak to your skill in helping people recover from mental and substance use disorders and maintain that recovery. Much of the time, this is sufficient for your clients to trust you enough to benefit from the help you offer them.

Yet, somehow, you may sense that this is not enough for many of your American Indian and Alaska Native clients. Your credentials seem less important to them than their assessment of you and of your ability to help them. The fact that you have opened this TIP says that you care about their perceptions. You want to help your clients, and if there are things you can learn that will help you earn the trust of your clients, you want to learn them.

Providing behavioral health services to members of a culture that is different from your own is not easy to do well. Grasping the nuances of another culture requires cultural self-awareness and the patience to learn, understand, and respect the expressions of the culture that you see and hear. Your curiosity about what you could do differently to be more effective with American Indian and Alaska Native clients in a way that works for them is a genuine asset. What is different about these clients that you need to better understand? How can developing your understanding help you provide more effective support, counseling, and treatment? This TIP will explore several responses to these questions.

Why a TIP on Working With American Indian and Alaska Native Clients in Behavioral Health?

American Indians and Alaska Natives have persistently experienced serious health disparities in access to care, funding, and resources for health services. They face disparities in the quality and quantity of services, treatment outcomes, and health education and prevention services. The availability, accessibility, and acceptability of services are all major barriers to substance abuse and mental health services for American Indian and Alaska Native people. Rural and remote areas often lack treatment infrastructure, and American Indian or Alaska Native individuals will sometimes delay seeking available care in part because they do not trust organizations. Other factors that influence participation include transportation, level of social support, perceived provider effectiveness, type of treatment setting, geographic location, and tribal affiliation.

In response to existing behavioral healthcare disparities, this TIP illustrates strategies for facilitating access to and engagement in treatment and describes promising practices for working with American Indians and Alaska Natives. It also provides tools and strategies for administrators to facilitate implementation of these practices. This TIP helps behavioral health service providers identify how and to what extent an individual's cultural background can affect his or her needs and concerns. It gives providers and administrators practical ideas and methods to deal with the realities of service delivery to American Indian and Alaska Native clients and communities.

Culturally responsive treatment requires establishing a standard of respect, focusing on strengths, and addressing underlying personal and historical trauma issues as appropriate (see definition on pages 20–21). Traditional interventions (both client centered and community centered) and care that are integrated with mainstream treatment methods are recognized as best practices for native communities.

Did You Know?

Practicing many cultural traditions was illegal for American Indians and Alaska Natives from 1878 until 1978, often resulting in imprisonment and fines for those who broke the law. Today, many tribes are working to restore important and protective cultural practices in their communities. These cultural practices are a pathway to prevention and healing.

Although some professionals have suspected that genetic factors play a part in the high rates of substance abuse among American Indians and Alaska Natives who use alcohol or drugs, this is incorrect. There are no genetic factors unique to Native Americans that are associated with high rates of substance use.

Suicide and suicide attempts are a significant problem in many American Indian and Alaska Native communities, especially among young men ages 15–24, who account for nearly 40 percent of all suicide deaths among natives. Native youth have a much higher suicide rate than youth or adults of other races. Suicide rates for Alaska Natives are more than double those for the U.S. population as a whole.

American Indians and Alaska Natives are less likely to drink than White Americans; however, those who do drink are more likely to binge drink and to have a higher rate of past-year alcohol use disorder than other racial and ethnic groups.

American Indians and Alaska Natives are more likely than White Americans or Latinos to abstain from alcohol and drugs. Among people who have been drinkers, American Indians and Alaska Natives are about three times more likely to have become abstainers than are former drinkers in the general population.

American Indians and Alaska Natives experience some mental disorders at a higher rate than other Americans (e.g., anxiety disorders). Although results vary, some research has found that Native Americans are less likely to have other disorders (e.g., major depression).

American Indians and Alaska Natives seek mental health services at a rate second only to that of White Americans and may be even more likely than White Americans to seek help, if one takes into account that many consult traditional healers for such problems. American Indians and Alaska Natives appear to be more likely than all other major racial and ethnic groups to seek substance abuse treatment services.

Likely reasons for today's high rates of substance use, suicide, violence, and domestic abuse among American Indians and Alaska Natives lie in the fact that their communities are exposed to a greater degree to the same risk factors that are predictors of problems for everyone, such as poverty, unemployment, and trauma (including historical trauma), as well as loss of cultural traditions.

Many American Indians and Alaska Natives report experiencing at least one traumatic event in their lifetimes, and all Native Americans have been affected by historical trauma across generations (sometimes referred to as “intergenerational trauma”).

American Indian and Alaska Native women report higher rates of victimization than women from any other racial or ethnic group in the United States. For example, American Indian and Alaska Native women are nearly twice as likely to be raped or sexually assaulted than are White or African American women. Nearly 80 percent of sexual assaults against Native American women are committed by non-native men (see Amnesty International, 2007; Bachman, Zaykowski, Kallmyer, Poteyeva, & Lanier, 2008; Tjaden & Thoennes, 2006).

Although more than 70 percent of American Indians live in urban areas, many maintain strong ties to their home reservations, making frequent visits and moving back and forth from cities to tribal lands.

Native American individuals have historical cause to wonder whether behavioral health service providers will recognize them for who they are, respect them, and offer assistance in walking their life path. History has taught tribes that it is dangerous to trust outsiders. Their people's lives—the lives of their parents and grandparents—have been taken or forever altered by outsiders.

Before You Begin

This TIP addresses the more common treatment needs of American Indians and Alaska Natives with behavioral health issues. However, the treatment concerns and pathways to healing presented in this manual will not—and cannot—equally and effectively represent all American Indian or Alaska Native individuals, communities, and tribes. There is simply much more diversity among American Indian and Alaska Native people than can be fairly represented here. Instead, the material can serve as a starting place, and you can adapt it to meet the unique attributes of each client and each client's cultural identity, treatment setting, community, and culture.

There are many distinct Native American cultures, and recognizing the diversity among tribes is important. Although clear similarities across native nations exist, especially when compared with mainstream American culture, not all American Indians and Alaska Natives hold the same beliefs or practice the same traditions. This also holds true for views on substance use and mental health, attitudes toward and beliefs about help-seeking, and treatment for mental and substance use disorders. Therefore, you as a provider must first invest in learning about and understanding the population and culture that you serve prior to selecting and adapting the material presented in this manual.

Some providers working with American Indian and Alaska Native clients find the use of diagnostic terminology in clinical work problematic, because the process of “naming” can have spiritual significance and may influence what is thus named. Providers should be careful when using such terminology with clients, although it may be essential in other clinical contexts.

The consensus panels expressed concern about the possible misuse of sacred ceremonies and traditional practices; therefore, to preserve and respect native ceremonies and heritage, no specific ceremonies are cited in detail. Without forethought, non-native providers may exploit native healing modalities by practicing traditional healing methods with clients. To avoid misuse of native healing modalities, native and non-native providers should rely on the community and native tribal council (governance) to guide the selection of traditional practitioners and the integration of traditional healing practices across the continuum of care. The consensus panels also agreed that identifying tribal affiliations for specific client case studies or examples could increase the risk of mistaken identification of individuals from a smaller tribe or a misrepresentation of tribal values and ways.

A thorough online literature review in Part 3 supports the manual. Parts 1 and 2 of this TIP use minimal citations to produce a user-friendly document, yet we recommend that you read the literature review. If you are interested in references associated with the presenting topics, please consult the literature review at https://store.samhsa.gov. To complement the materials presented in this TIP, the consensus panel suggests that providers, including counselors, other clinical staff members, program directors, and administrators, read TIP 59, Improving Cultural Competence (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014a).

Consensus Panel Perspectives

Throughout the consensus process, several themes emerged from many conversations, as well as shared experiences and stories among panel members. As you read and reflect on the material presented in this manual, keep these core concepts at the center of your attention and let them guide your practice.

Importance of historical trauma. As a provider, you should recognize, acknowledge, and address the effects of historical trauma in the treatment process (see the section in Part 1, Chapter 1, titled “The Importance of History for American Indian and Alaska Native Behavioral Health”). Although native people across North America share similar experiences of loss and trauma, each tribe has its own story of contact with Europeans. Most American Indians and Alaska Natives believe that historical trauma, including the loss of culture, lies at the heart of substance use and mental disorders within their communities. Typically, providers consider it important to obtain clients' psychosocial history prior to any medical or psychological treatment and place less emphasis on addressing the history and role of trauma. However, in treatment for American Indians and Alaska Natives, it is critical to incorporate the role of historical trauma in assessments, in developing treatment plans, and in implementing healing strategies.

Acceptance of a holistic view of behavioral health. The view of substance use and mental disorders—their definition and nature—among American Indian and Alaska Native people is markedly different from mainstream beliefs. Among many Native Americans, substance use and mental disorders are not defined as diseases, diagnoses, or moral maladies; they are not physical or character flaws. Instead, substance abuse is seen as a symptom, reflecting an imbalance in the individual's relationship with the world. Keeping with this holistic worldview, healing and treatment approaches need to be inclusive of all aspects of life—both seen and unseen—incorporating the spiritual, emotional, physical, social, behavioral, and cognitive. No one aspect is separate from the others, and all provide a path to recovery, with room to embrace traditional healing and mainstream treatment practices along the way.

Role of culture and cultural identity. Mental and substance use disorders are frequently seen as the consequences of culture loss among American Indian and Alaska Native communities. Maintaining ties to one's culture can help to prevent and treat substance use and mental disorders; thus, healing can come from reconnecting. Through reconnection to native communities and traditional healing practices, an individual may reclaim the strengths inherent in traditional teachings, practices, and beliefs and begin to walk in balance and harmony. In translating this belief into practice, initial interviews and assessments need to be culturally responsive (e.g., inquiring about the client's involvement in traditional and healing practices).

Providers need to understand how clients perceive their own cultural identity and how they view the role of traditional practices in treatment. Providers need to adapt treatment planning to match clients' needs and treatment preferences. Not all American Indian and Alaska Native clients recognize the importance of culture or perceive a need for traditional practices in their recovery. Nonetheless, providers and treatment programs must be flexible to match their clients' needs, rather than expecting the client to adapt to match the treatment program, regardless of whether it is native or non-native.

Recognition of sovereignty. Tribal governments are sovereign nations. Each nation adopts its own tribal codes and has a unique history with the federal government. Providers in native and non-native programs need to understand the role of tribal sovereignty and governance systems in treatment referrals, planning, cooperative agreements, and program development.

Significance of community. Creating culturally responsive services requires the participation of the native community, including leaders (formal and informal), councils, clients, potential clients, and client families. Even though it may appear less time consuming, complex, and expensive to avoid community participation, doing so represents an example of paternalism, in which the administrators or providers assume that they inherently know what is best for the program, client, staff, and community.

Instead, clients and the community should have an opportunity to provide input on the type of services needed and how those services are rendered. Without this information, services may be poorly matched to clients and underused by the community, and may further drain the agency's and tribe's financial resources. For example, providers may overlook that the program location offers minimal privacy for clients seeking help, especially in rural and reservation settings. Unbeknownst to providers, clients may be reluctant to drive and park at the building for fear of being seen. With community involvement, providers are more likely to learn of potential obstacles and plan accordingly.

Additionally, American Indian and Alaska Native beliefs revolve around the value of connectedness and the importance of relationships. If providers do not build relationships or demonstrate interests in the community, the native community may be less accepting of the services offered. Providers need to take time to be involved in community events and to create ways to encourage community involvement in treatment services.

Value of cultural awareness. Providers who have a general understanding of how culture affects their own worldview (as well as that of their clients) will be able to work more effectively and be better equipped to respect clients who have diverse belief systems. If providers are cognizant of their own cultural backgrounds, they will be more likely to acknowledge and explore how culture affects their interactions, particularly their relationships with clients.

Without cultural awareness, providers may offer counseling that ignores or does not address issues that relate specifically to race, ethnic heritage, and culture. This lack of awareness can also lead to discounting the importance of how their own cultural backgrounds—including beliefs, values, and attitudes—influence their initial and diagnostic impressions of clients. Providers may unwittingly use their own cultural experiences as a template to prejudge and assess clients' experiences and clinical presentations. They might struggle to see the cultural uniqueness of clients, assuming that they understand clients' life experiences and backgrounds better than they really do. With cultural awareness, providers examine how their own beliefs, experiences, and biases influence their definitions of normal and abnormal behavior, illness, and healing.

Commitment to culturally responsive services. Organizations have an obligation to ensure high-quality care and the cultural competence of all personnel. The first aim is to protect the welfare of clients. Cultural competence is important at all levels of operation in behavioral health services: individual, programmatic, and organizational. It is also important in all activities and at every treatment phase—outreach, initial contact, screening, assessment, placement, treatment, continuing care, and recovery services—as well as with research, prevention, and education. Culturally responsive practice recognizes the fundamental importance of language and the right to language accessibility, including translation and interpreter services.

Culturally responsive services will likely provide clients with a greater sense of safety, supporting the belief that culture is essential to healing. Although not all clients identify or want to connect with their cultures, culturally responsive services offer clients a chance to explore the impact of culture, history (including historical trauma), acculturation, discrimination, and bias and how these relate to their behavioral health.

Significance of the environment. An environment that reflects American Indian and Alaska Native culture will be more engaging to clients and set a tone that indicates respect. The program should take specific steps to make the facility more accessible and culturally appropriate. In addition, the organization should work to create a more culturally reflective environment—not only within the facility, but also through business practices, such as using local and community vendors when possible.

Respect for many paths. There is no one right way. Providing direction on how something should be done is not a comfortable or customary practice for American Indians and Alaska Natives; the consensus panel expressed this sentiment while discussing treatment approaches. Most data on evidence-based practices (EBPs) are not based on native participation. Evidence- or science-based practices are practices that have emerged from mainstream culture. Although EBPs have value, practice-based approaches and traditional healing practices play a significant role in Indian Country. Inherently, introducing the necessity of using EBPs suggests that there is one right way of doing things. This approach can be seen as an attempt by mainstream treatment providers to impose specific treatment methods on native communities while devaluing traditional healing practices and beliefs. To American Indians and Alaska Natives, healing is intuitive; is interconnected with others; and comes from within, from ancestry, from stories, and from the environment. Instead of one right way, there are many paths to healing.

You Can Do This!

You are likely aware that people who grow up in cultures different from your own may think differently than you do about many things. They have had different experiences than you might have had and generally have attitudes and beliefs about many things that are at least slightly different—if not very different—from yours. You may know this instinctively when you visit a foreign country, an Alaskan Native village, or an American Indian reservation. Things are different, and these differences go far beyond the difficulty of reading signs in another language or finding familiar food on a menu. You observe that people have created a way of life that is grounded in their land and language and expressed in their beliefs, customs, communication styles, and relationships—their lives have a different rhythm or pace from yours. As you proceed in your work, remember you are the visitor, the guest, the “different” one. Take time to observe, learn, and participate.

You already have plenty of knowledge and skills in your field of practice. You know about mental health and substance abuse and how to carry out your own role in the continuum of prevention, assessment, intervention, treatment, and recovery. You have developed interpersonal, clinical, and psychoeducational skills that work well in connecting you to many of your clients. You are likely caring as well as competent. You are also interested in improving your ability to help your clients—in this case, your American Indian and Alaska Native clients. Pursuing this learning is as much personal as it is professional. You may learn new things about your own perspectives on life as you come to understand those of others. It can be a rich journey.

Choosing a Path for Your Learning Journey

In this publication, you will explore how you interact with your clients and adapt culturally responsive ways of healing. To this end, the TIP emphasizes four main content areas. First, it explores the basic elements of American Indian and Alaska Native cultures; more knowledge prepares you to listen in a new way, tuning in more carefully to your American Indian and Alaska Native clients. Second, the manual emphasizes the importance of becoming aware of and identifying cultural differences between you and your clients, whether you are a native or non-native provider. By avoiding assumptions of similarity and taking the time to understand your clients' unique cultural identities and perspectives, these attitudes and actions can lead to a stronger and more trusting relationship. Third, the TIP highlights cultural beliefs about illness, help-seeking, and health. Fourth, it offers practice-based approaches and activities informed by science and the healing power available through native traditions, healers, and recovery groups.

A circle is the best image to organize the information that you will need to work competently with American Indian and Alaska Native clients. The circle is a widely shared symbol among native cultures; all of life, seen and unseen, moves in circles and cycles. The circle symbolizes a key philosophy for understanding the relationship of people to everything in their environment and represents many things to American Indians and Alaska Natives. It represents the circle of life, the seasons, unity and harmony among all creation, and the importance of striving for balance and harmony. One lesson that the circle teaches is that there is no right or wrong within the circle, merely different viewpoints and pathways that are influenced by life experience, family, community, and environment (Cruickshank-Penkin & Davidson, 1998).

The circle graphic on the next page models the key elements for providing culturally responsive care for American Indians and Alaska Natives in behavioral health services. The concentric circles highlight the primary audience for each part of the TIP: providers, administrators, and researchers. The outermost shaded band symbolizes the importance of cultural, environmental, and historical factors that influence the effectiveness of services across the continuum of care. Each quadrant of the circle represents an essential ingredient in supporting culturally responsive services for American Indians and Alaska Natives. Adapting Sue and Sue's (2013) multidimensional model of cultural competence, the four ingredients (beginning in the East) are cultural knowledge, cultural awareness and competence, cultural perspective on behavioral health, and culturally specific and responsive skills and practices.

To your American Indian and Alaska Native clients, you are the embodiment of your message; they expect that you are an expert at what you do. What will they encounter when they are with you? Will you see them? Will you understand who they are? Will you respect their ways of seeing things and their goals, although they may be different from your own viewpoints and your own goals for them? American Indian and Alaska Native clients often do not care what you know until they know that you care. How can you demonstrate caring?

“Everything the power of the world does is done in a circle. The sky is round, and I have heard that the earth is round like a ball and so are all the stars. The wind, in its greatest power, whirls. Birds make their nests in circles, for theirs is the same religion as ours. The sun comes forth and goes down again in a circle. The moon does the same and both are round. Even the seasons form a great circle in their changing and always come back again to where they were.”

—Black Elk, Oglala Sioux (as interpreted by J. G. Neihardt)

Source: Black Elk & Neihardt, 1932, p. 121.

Your journey around the circle begins in the East, where the day dawns. East is the direction of awakening, newness, and beginnings. The East is about learning and understanding American Indian and Alaska Native cultures as much as you are able. The East explores historical roots, historical trauma, current native experiences, cultural worldview, beliefs, and values. What is the importance of these to your clients today? What do you need to know to work with your clients?

In the South, you should look at the importance of your culture in your work and consider the roots of your own views, assumptions, values, and practices. In the South, you see similarities and differences and open yourself to learn. This quadrant is about becoming culturally aware and competent. Here, you focus on the roles of culture and cultural identity in the provider–client relationship.

Continuing to the West, you will learn how your clients might view their own needs for healing and change and their ideas about help-seeking, treatment, healing, recovery, and prevention. What are your clients' beliefs about illness? This quadrant focuses on the holistic view of behavioral health.

The North is where you will learn to wisely implement the clinical skills that ensure the use of culturally responsive interventions, including traditional and best practices. This quadrant highlights practice-based approaches and activities informed by science and by the healing traditions of native healers, medicine, and recovery groups. The North also signifies a time of transition—changing things to make them better as you continue your path.

Beginning in the East: The Direction of Cultural Knowledge

In the circle, East is the direction of preparation, beginnings, and grounding. This section will help you to better understand the American Indian and Alaska Native experience of life, both historically and currently. This section begins with a discussion of Native American history, followed by a discussion of how that history continues to affect contemporary American Indians and Alaska Natives. It then presents some information about American Indians and Alaska Natives today and some challenges that many Native Americans face.

American Indian and Alaska Native History: Effects of Colonization

A grasp of events in their people's past is essential for understanding American Indian and Alaska Native clients today. The American history you learned in school most likely began in the 17th century and was about European settlers and their descendants. This does not reflect the experiences of American Indians and Alaska Natives. This summary of American Indian and Alaska Native history does not do justice to the richness of their past, but it can give you a sense of the centuries-long evolution of their cultures and how the lives of Native Americans have been disrupted by contact with other peoples. Ever since the Europeans' arrival and colonization of North America, the history of American Indians and Alaska Natives has been tied intimately to the influence of European settlers and to U.S. government policies. The lives of American Indians and Alaska Natives today are, to some extent, the result of their mistreatment at the hands of European (including Russian) settlers. Early colonists would not have survived without the assistance of Native Americans, yet within a relatively brief span of years, those colonists were killing their native hosts to claim land, degrading their environment, exposing them to infectious diseases from which their natural immunity could not protect them, and even enslaving them.

Many native communities have origin stories. Passed down from one generation to the next, these symbolic and traditional narratives explain creation—the beginning of life, of place, and of the world—and are shaped by the individual community's culture, region, and language. Many origin stories and legends have been passed through oral tradition, but some have been recorded for preservation. Origin stories prescribe how people should be in the world and their responsibilities to the Earth and to each other. These stories have great relevance in providing care and in healing. (For a review of oral narrative themes and an annotated list of resources across regions, see Bastian and Mitchell, 2004.)

In early colonial times, European settlers and American Indians established some mutually profitable trading networks on the East Coast. However, the Spanish used American Indian forced labor in mines and on ranches in the Southwest, the British forcibly took land for agriculture, and the Russians captured Alaska Natives for work in the fur trade. American Indians and Alaska Natives increasingly resisted European attempts at dominance but found themselves repeatedly defeated in local wars. As a result, they lost population, land, and power.

Shortly after the U.S. government was created, the Northwest Ordinance laid out policies that allowed confiscation of native lands in exchange for the payment of goods and monetary annuities. A department was established to keep track of the treaties signed and the funds disbursed and was later upgraded to a bureau. The Indian Office became part of the War Department in 1824 and moved to the Department of the Interior in 1849. Unfortunately, the treaties were often broken, ignored, or forgotten.

In 1830, as American settlers pushed westward, Congress passed the Indian Removal Act to force American Indians to relocate west of the Mississippi River. It was believed that American Indians could be more readily assimilated into mainstream culture if they were concentrated in one area; they could be “civilized,” and their native cultures would disappear. Whether voluntarily or by force after a military defeat, brutal marches of American Indians ensued, and the loss of life was tremendous. In the southeastern United States, an estimated 100,000 Cherokee, Choctaw, Creek, Chickasaw, and Seminole people were relocated in wintertime, during which thousands died of disease and starvation; this is known as the Trail of Tears.

Within 10 years, the resettlements to what are now Nebraska, Kansas, and Oklahoma were completed, but intertribal conflicts surfaced. The American Indians who now had to share their land resented the new arrivals. American settlers moved into new areas, the Indian Office became more corrupt, and pressures on hunting grounds and reservation lands increased. More tribes were sent to live on reservations of marginal land where they had little chance of prospering. The Plains tribes suffered the extermination of buffalo herds, depletion of water resources, economic depredation, and loss of human lives (Hirschfelder & de Montaño, 1993).

The Indian boarding school movement began about 1875 as a part of an effort to assimilate American Indian and Alaska Native children into mainstream culture. The government removed children from their families and communities, often by force, and placed them in schools often hundreds and even thousands of miles away from their homes. In some areas, generations of families attended boarding schools. By 1899, there were 26 off-reservation schools scattered across 15 states. The number of boarding schools grew, and by the 1930s, nearly half of all American Indian and Alaska Native children were enrolled in a boarding or industrial school. Some schools were still operating as recently as the 1970s. The emphasis within the Indian educational system later shifted to reservation schools and public schools, but boarding schools continued to have a major impact for many years thereafter because they were perceived to be an effective means of assimilating American Indians into mainstream culture. The boarding school experience also prevented the transmission of tribal culture, language, traditional parenting skills, and naturally occurring patterns of family socialization. Recently, the extent of child physical and sexual abuse that occurred at the boarding schools has come to light. A 1990 report, published by the National Resource Center on Child Sexual Abuse, found widespread abuse occurring over years, particularly at missionary schools.

President Grover Cleveland signed the General Allotment Act (also known as the Dawes Severalty Act) in 1887. This law broke up reservation land into portions allotted to Indian families and individuals. The government then sold the leftover reservation land at bargain prices. This Act, intended to encourage American Indians to farm the land and otherwise integrate them into U.S. society, had disastrous consequences. In addition to losing surplus tribal lands, many natives lost their allotted lands in future sales and had little left for survival (Hirschfelder & de Montaño, 1993).

The Bureau of Indian Affairs (BIA) intruded further into Native American life in the early 20th century. Community celebrations were prohibited, and BIA workers assumed management of reservation health care, education, public safety, and road maintenance. The Meriam Report (known by the surname of its author, Lewis Meriam, but officially titled The Problem of Indian Administration), published in 1928, exposed problems that had worsened under this system and marked a policy change that resulted in passage of the Indian Reorganization Act in 1934.

Indian policy shifted again near the end of World War II. Congress began to withdraw federal support and to abdicate responsibility for Native American affairs. Over the following two decades, under a policy known as “termination,” many federal services were withdrawn, and federal trust protection was removed from tribal lands and given to the states. At the same time, the Indian Relocation Act encouraged Native Americans to move to urban areas where they were more likely to find jobs. This further weakened tribal ties and sense of community (Hirschfelder & de Montaño, 1993). Many families never returned to their reservations.

Self-determination became the new watchword of policy toward American Indians and Alaska Natives in the late 1960s and 1970s. The Indian Self-Determination and Education Assistance Act of 1975 codified the policy, which repudiated termination policies and permitted tribes to enter into contracts to manage aspects of tribal governance, such as education. The Indian Child Welfare Act of 1978 put an end to the practice of adopting out American Indian and Alaska Native children into non-native homes. In keeping with self-determination, the American Indian Religious Freedom Act of 1978 ended the ban on traditional spiritual practices. Despite the prohibitions and Christianizing efforts by various churches, indigenous culture and spirituality have survived and are widely practiced. Even in areas where many American Indians and Alaska Natives practice Christianity, traditional cultural views still heavily influence the way in which Native Americans understand life, health, illness, and healing (Kalt et al., 2008).

An important class action suit, known as Cobell v. Salazar, was filed on behalf of a large group of American Indians against the Departments of Treasury and the Interior in 1996. It asserted that the government had failed to account for monies held in trust since tribal lands had been allotted to individuals beginning in 1887; that other assets held in trust had been mismanaged; and that royalties were owed to individuals for leases of their lands for grazing, oil, gas, and other resources. The issues in the suit were enormously complex, and it was not settled until 2010. The government agreed to set aside $3.4 billion, of which $1.5 billion would compensate approximately 500,000 individuals, and $1.9 billion would buy back land to benefit tribes (Campbell, 2013).

AMERICAN INDIANS AND ALASKA NATIVES IN MILITARY SERVICE

Approximately 12,000 American Indians and Alaska Natives volunteered for military service in World War I—an estimated 25 percent of the total male American Indian population at the time (Britten, 1997). During World War II, more than 44,000 Native American men and women served in the military. This is about 13 percent of the 350,000 individuals that made up the American Indian and Alaska Native population at the time (Armed Forces History Museum, 2013).

In World War I, the U.S. military began using American Indians and Alaska Natives as code talkers. Initiated by Choctaws in World War I, American Indians and Alaska Natives used their language in a code for transmitting messages on the battlefield. The code was never broken. During World War II, the armed forces began to recruit Kiowa, Cherokee, Navajo, Tlingit, Comanche, Seminole, and at least 25 other tribes and nations to transmit coded messages. Beginning in 2000, 29 code talkers were awarded special Congressional Gold Medals for their service (National Museum of the American Indian, 2007).

Five American Indians received the Congressional Medal of Honor for their service during World War II, and three received it for their service in the Korean War (Center for Military History, United States Army, 2011).

The experience of Alaska Natives with foreign cultures was, in some ways, similar to that of American Indians, but the basic state history is quite different, owing in part to its climate and geography. The Aleuts were the culture most affected by contact with Russian explorers and fur traders after their arrival in the early 1700s. Few Russians actually settled in Alaska, but they were able to coerce the Aleuts into doing their marine hunting for them, using Alaskan seaworthy vessels and weapons that were well suited to this pursuit. Other inhabitants of coastal areas, such as the Yup'ik, Chugach, and Tlingit, who relied on fishing and hunting, were also affected (Korsmo, 1994).

No land was set aside for Alaska Natives to use. They simply lived where they chose and inhabited much of the land, particularly where game, fish, and other foods were plentiful. Yet, as among American Indians, missionaries undertook the assimilation of the native population by forbidding the use of traditional languages and customs and sending the children to boarding schools where they would become more “American.” Physical, emotional, and sexual abuse by adults and other students at these schools added to the losses of family relationships and cultural traditions (LaBelle, 2005).

With the purchase of Alaska in 1867 and the discovery of gold near Juneau in 1880 and in the Yukon in 1896, the area became a valuable asset to the United States. According to the Mining Act of 1872, however, Alaska Natives were not permitted to stake mining claims, and they were often paid less than Whites for the same work (Ongtooguk, n.d.). Schools for Alaska Natives were operating under federal supervision within 20 years. Alaska became a U.S. territory in 1912. Generally, Alaska Natives' land claims were respected in accordance with the 1884 Organic Act, but there were some problems. For example, the Alaska Native Allotment Act, passed in 1906, provided reservation land only for hospitals, schools, and reindeer (Korsmo, 1994).

Alaska Natives were reorganized by law in 1936. Few groups chose to create reservations. Many Alaska Natives were opposed to reorganization, as was the territorial governor, who feared that the Alaska Native groups would stagnate and that reservations would become subsistence enclaves. Commercial fishing and canning industries opposed reservations, as they wanted to ensure access to water (Korsmo, 1994).

Alaskan statehood, granted in 1959, became the catalyst for clarification of natives' land claims. If their claims were to be respected as required by the 1884 treaty, mining, oil, and other industries could not confiscate Alaska Native territory. These land issues mobilized Alaska Natives to form the Alaska Federation of Natives in 1966. Representatives of 17 native organizations met to present a united voice for a fair settlement.

Five years later, the Alaska Native Claims Settlement Act resolved land issues by law. Alaska Natives would receive the title to 40 million acres of land that they already occupied. To compensate them for the loss of their claims to other lands, they would also receive nearly $1 billion over 11 years; Alaska Natives would be organized into 12 corporations that would administer the land and funds (R. S. Jones, 1981).

Although it appears that governmental agencies have become more aware of past injustices toward American Indians and Alaska Natives, it is difficult—if not impossible—to make amends for centuries of disrespect and hostility. American Indians and Alaska Natives have demonstrated their resilience and have responded to the self-determination mandate by taking control of tribal government; by fostering economic development of reservations; and by making their voices heard on environmental, healthcare, and other issues that affect them.

Exhibit 1.1-1 provides information on major events in American Indian and Alaska Native history. Not all events are included in both the previous narrative and the timeline, so you may benefit from reading both.

Box Icon

Box

EXHIBIT 1.1-1. Timeline of Significant Events in Native American History.

The Importance of History for American Indian and Alaska Native Behavioral Health

The overview of historical events presented above shows that for more than 500 years, American Indians and Alaska Natives have endured multiple traumatic events as a result of colonization. As a behavioral health service provider, you need to be aware that your American Indian and Alaska Native clients continue to experience repercussions from these events. It may be difficult for you to read and think about these events, in part because you know that they have had such damaging effects on American Indians' and Alaska Natives' lives (discussed in the next section), but an understanding of how trauma affects clients is vital to your effectiveness as a provider.

Clinicians and researchers call the process through which past traumatic events affect one's present-day functioning historical trauma. Historical trauma has been defined as the “cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma” (Brave Heart, Chase, Elkins, & Altschul, 2011, p. 283).

Another author has described historical trauma as “collective complex trauma inflicted on a group of people who share a specific group identity or affiliation—ethnicity, nationality, and spiritual affiliation. It is the legacy of numerous traumatic events a community experiences over generations and encompasses the psychological and social responses to such events” (Evans-Campbell, 2008, p. 320). It is collective in that it affects an entire people, rather than an individual, and complex in that it does not have a single traumatic cause. Historical trauma has also been referred to as a “soul wound” that affected and continues to affect the physical, social, cultural, and psychological health of American Indians and Alaska Natives (B. Duran, Duran, & Brave Heart, 1998).

Dr. Maria Yellow Horse Brave Heart applied the concept of historical trauma to American Indians and Alaska Natives when she noted parallels between Holocaust survivors and their children and American Indians and Alaska Natives whose ancestors had suffered massive trauma. She observed that contemporary American Indians and Alaska Natives continued to experience grief about traumatic events in their history that they were unable to resolve, and this was further exacerbated by additional disruptions in native cultures (e.g., forced out-of-home placement of children into boarding schools, the banning of traditional ceremonies and practices), which in turn affected traditional responses to grieving, such as described in “Traditional Cultures and Historical Trauma” (Brave Heart et al., 2011).

TRADITIONAL CULTURES AND HISTORICAL TRAUMA

A stronger connection to traditional cultures may help reduce the effects of historical trauma on American Indians and Alaska Natives, as the loss of traditional cultural practices may have exacerbated the effects of historical trauma. Brave Heart (2003) gives an example of this drawn from Lakota history. The Lakota culture had specific rituals and practices for grieving that allowed for a year of publicly expressed mourning, followed by a ceremony to heal that grief. U.S. policies outlawing native ceremonies interrupted the process of grieving over events such as the Wounded Knee Massacre of 1890, in which the U.S. Army killed between 150 and 300 Lakota men, women, and children.

You may find that your American Indian and Alaska Native clients experience grief for somewhat different reasons than other clients do. Common reasons for grief include the loss of their communities, loss of life, loss of freedom, loss of land, loss of self-determination, loss of traditional cultural and religious practices, loss of native languages, and the removal of children from their families. Historical trauma may involve events that happened hundreds of years ago or more recent traumatic events, such as forced placement in boarding schools or environmental disasters (e.g., the Exxon Valdez oil spill, gasoline pipeline breaks on the Crow reservation in Montana), which have done both material and cultural harm.

Brave Heart and others found that traditional models of responses to trauma were inadequate to explain the whole complex of behavioral and social problems that American Indians and Alaska Natives have experienced. When you view the larger picture, historical trauma appears to contribute to various problems, including socioeconomic effects, problematic behaviors, and, especially, various mental and substance use disorders. Other relevant factors that mark historical trauma as different from other trauma are that the distress resulting from the trauma is collective rather than individual, and the cause of trauma comes from people outside the community affected by it (Evans-Campbell, 2008). Historical trauma is also intergenerational in that the original trauma continues to have effects on subsequent generations that did not experience it directly.

You might find it helpful in your practice to use some of the measures that have been developed to evaluate how salient historical trauma is for your clients. Research using those measures does indicate that American Indians and Alaska Natives frequently think about historical losses (Whitbeck, Adams, Hoyt, & Chen, 2004).

The Effects of Historical Trauma on American Indians and Alaska Natives Today

Many providers who work with American Indians and Alaska Natives believe that historical trauma can cause anger, grief, and shame that contribute to substance use disorders, suicidality, and increased vulnerability to mental disorders such as posttraumatic stress disorder (PTSD). These, in turn, increase risk for additional trauma, perpetuating its effects (Exhibit 1.1-2).

Box Icon

Box

EXHIBIT 1.1-2. Cycle of Historical Trauma.

Traumatic events often have material, economic, psychological, and cultural repercussions. Among American Indians and Alaska Natives, historical loss is associated with greater risk for substance abuse, depressive symptoms, more feelings of anger, and a higher likelihood of engaging in binge eating (Clark & Winterowd, 2012; Ehlers, Gizer, Gilder, & Yehuda, 2013; Whitbeck et al., 2004; Whitbeck, Walls, Johnson, Morrisseau, & McDougall, 2009). Historical trauma may also affect future generations in a number of ways at national, community, family, and individual levels (Sotero, 2006). Trauma can affect future generations physically (e.g., by raising the risk of certain diseases), socially (e.g., by increasing child abuse and domestic violence), psychologically (e.g., by causing depression or PTSD), and spiritually (e.g., by losing hope for the future). Some theorists suggest trauma is also stored on a biological level; that is, one generation passes it down to the next.

One important way historical trauma is transmitted across generations is through its effects on parenting. Brave Heart (1999) suggests that trauma experienced by parents can disrupt traditional parenting practices and increase substance abuse, which in turn negatively affects parenting. Trauma may affect trust and intimacy and the ability to form a healthy bond with one's children. Parents tell stories of historical events or of their own experiences that may cause secondary traumatization. Children also witness and, to some extent, internalize their parents' reactions in times of stress when their parents' responses to traumatic situations are triggered.

STORY OF THE SACRED HOOP OF 100 EAGLE FEATHERS

“In Black Elk's vision, the Hoop of the World referred to the communities of Native people. In his vision, he saw the Native people going through a long time of suffering during which the hoop was broken. And then he saw that the people would begin to heal. The Elders have told us that we have now entered the time of healing and the ‘coming together time.’ The Sacred Hoop is the symbol of that time of healing. The Sacred Hoop of the Wellbriety Movement was born from a vision in 1994….”

Mission of the Sacred Hoop: Healing Individuals, Families, Communities, and Nations

“The Hoop was built in a sweat lodge over a weekend in May of 1995. On the first day of summer that year, a multicultural Elders gathering was held in Janesville, WI, to provide prayers for the Hoop and align its purpose to the coming healing time. The Elders placed the four gifts of Healing, Hope, Unity, and the Power to Forgive the Unforgivable into the Hoop. The first Sacred Hoop Journey began in the spring of 1999.”

“Since the Sacred Hoop was blessed, it has traveled over 53,000 miles to Native American communities across the United States…. When the Sacred Hoop comes to a community, the people gather for ceremonies and talk about living a sober and healthy life that is balanced emotionally, mentally, physically, and spiritually.”

Source: Coyhis, 2007. Reprinted with permission.

Adverse childhood events, beyond actual trauma and including things such as parental illness or inadequate family resources, affect the psychological development of children and increase their risk for problems such as PTSD and substance abuse. TIP 57, Trauma-Informed Care in Behavioral Health Services, includes additional information on the effects of trauma on parenting and on behavioral health in general (SAMHSA, 2014b).

The Benefits of Focusing on Historical Trauma

The concept of historical trauma is intended to help you, the provider, find ways of discussing current trauma and emotional or behavioral problems in a context that is not “stigmatizing” (Brave Heart et al., 2011). By working with a concept of historical trauma, you can present trauma as a collective experience, and thus one that communities can work together to overcome (Gone, 2013). You may find that the most effective methods of treating the effects of historical trauma typically involve families and communities and supportive networks of people working to overcome similar problems or challenges (e.g., tribal canoe journeys in the Pacific Northwest). These networks often work to connect clients with their traditional cultural beliefs and practices and may include tribal elders and healers who offer spiritual guidance and healing in a manner that is congruent with American Indian and Alaska Native beliefs.

American Indians and Alaska Natives Today

If you have even a modest familiarity with American Indians and Alaska Natives, you know that they lead diverse lives. American Indians and Alaska Natives are professionals, business people, scientists, academics, athletes, artists, soldiers, teachers, community builders, and clergy. They are hunters, fishers, harvesters of wild and cultivated foods, and medicine men and women or traditional healers.

Your clients may live in a relatively small geographic area and share a tribal identity. As a whole, the American Indian and Alaska Native population is extremely diverse and encompasses people from 573 federally recognized tribes, each with its own culture, and many more tribes that are recognized by states only or that are seeking federal recognition (Indian Entities Recognized, 2018). American Indians and Alaska Natives speak more than 150 different languages, and diverse tribes have varying customs and beliefs. American Indians and Alaska Natives, even those from the same culture, may have widely differing levels of identification with those native cultures.

“We are many. We are diverse. We represent our many cultures. We are a resource. We influence our people. We have roots and heritage. We live in two worlds. We feel unity when we gather. We have dual citizenships. We are the caretakers for many of our aging elders and children. We are the link to those who have left home. We are you.”

—Katherine Gottlieb, Aleut, President, South Central Foundation, Anchorage, AK

Source: National Urban Indian Family Coalition, 2009, p. 5.

As a provider, you know the importance of treating each client as an individual. With that in mind, much of the information that follows describes how American Indians and Alaska Natives as an entire population differ from other groups and may not apply to specific American Indian and Alaska Native clients. Talking individually with your clients about their culture and its meaning to them is essential before you make decisions about how to treat those clients. The West section presents a discussion of assessment, including the assessment of cultural identification, and TIP 59 (SAMHSA, 2014a) contains a chapter on culturally responsive evaluation and treatment planning.

According to Census estimates released in 2018, 6.8 million people in the United States identified as Native American, either alone or in combination with another race. This number represented only 2.1 percent of all people in the United States. Of those 6.8 million, 4.1 million identified solely as Native American, and 2.7 million identified as Native American in combination with another race (Census Bureau, Population Division, 2018).

The number of people who identify as Native American has been growing since the 1960s. This appears to be because a growing percentage of the population has chosen to identify as Native American. The choice often is based on people's Native American ancestry, not because of cultural affiliation. This is a subject of some debate within the American Indian and Alaska Native population, with some individuals welcoming these “new” Native Americans and others being concerned that these individuals are ignoring the importance of American Indian and Alaska Native cultures in defining themselves as Native American. For the latter group, belonging to an American Indian and Alaska Native tribal entity is the best way to identify whether someone is “culturally” Native American (Gone & Trimble, 2012).

The American Indian and Alaska Native population is younger than the United States population as a whole, with a median age of 31.3, compared with 38.0 for the whole population (Census Bureau, Population Division, 2018). One unfortunate reason for this is that American Indians and Alaska Natives tend to die earlier from a number of health problems (see the discussion under the “Physical Health” section). Like other Americans, most American Indians and Alaska Natives work in urban areas, but they are more likely than the population as a whole to live in rural areas. According to the HHS Office of Minority Health (2018), 60 percent of American Indians and Alaska Natives live in urban areas. About 22 percent live on reservations or off-reservation trust lands. American Indians and Alaska Natives whose primary residence is on reservations, trust lands, or bordering rural areas often migrate between cities and those rural areas and maintain ties in both areas.

WHO ARE NATIVE AMERICAN TRIBAL MEMBERS?

Having Native American ancestry does not automatically qualify a person as a member of a Native American nation or tribe. Tribal members are those who are officially enrolled in a tribe or similar entity. Tribes have the right—because they are sovereign nations with their own governments—to decide who is and is not a member. The criterion used most often by tribes is “blood quantum,” or documentation that one is descended from historical tribal members. Blood quantum refers to the amount of tribal blood a person possesses as determined by his or her ancestors. In some tribes, a person might be full-blooded Native American but may not meet the requirement for tribal membership, because some ancestors were members of other tribes.

American Indians and Alaska Natives account for a greater proportion of the population in certain states, particularly Western ones. According to the Census Bureau's Population Division (2018), the states with the highest proportion of native populations are Alaska (where native people make up 20.0 percent of the population), followed by Oklahoma (13.8 percent), New Mexico (12.2 percent), and South Dakota (10.4 percent).

The Status of American Indian and Alaska Native Tribes

American Indians and Alaska Natives are unique among racial/ethnic groups in the United States. In addition to being U.S. citizens only since 1924, they may be members of federally recognized sovereign nations or tribes within the United States. As of this publication, the U.S. government has recognized 573 tribal entities (Indian Entities Recognized, 2018). Other native communities are only recognized by certain states or are in the process of applying for recognition. Not all nations refer to themselves as “tribes.” For example, American Indians in the Southwest may refer to their nation as a pueblo, other tribes may refer to their community as a “band,” and Alaska Natives may identify according to the village to which they belong.

These sovereign nations are subject to federal law, but to only some state laws. Federal law recognizes that native sovereign nations have the authority to manage certain functions of their own government on tribal lands and that, in turn, the federal government has a duty to protect members of these nations and to provide them certain services (e.g., health care) according to obligations set out in treaties with individual tribes.

U.S. GOVERNMENT TREATIES

Treaties are made between the governments of nations. Therefore, making a treaty was a recognition by the U.S. government (and earlier, European and colonial governments) that native communities were sovereign nations and that the land belonged to the native communities that were granting rights to it in exchange for certain guarantees and payments. Those treaties and federal laws enacted afterward meant that the federal government had legal and financial responsibilities in relation to federally recognized tribes.

Much of the time, especially early on, these treaties made little sense to tribes. The agreements were explained in languages foreign to them and were presented in a written form that was incomprehensible to the tribal leaders, so they were forced to rely on interpreters to understand what was being proposed. The whole concept of owning land and rights to it was alien to American Indian and Alaska Native people. The fact that the United States did not fulfill its treaty obligations created a complex network of problems that took decades to untangle. Nevertheless, recognition of the sovereignty of native communities has provided the foundation of the tribes' claims on the United States ever since.

American Indians and Alaska Natives governed themselves and related to each other as sovereign nations long before the European colonization began. Tribal authorities today may police their own lands, create laws to govern them, manage their own courts, provide other essential services, provide housing, run schools, and, in some cases, manage health care in part through the use of IHS funds. Some tribes also run businesses for the benefit of tribal members. Research suggests that native people who have self-governance are more economically prosperous and may have better behavioral health outcomes, such as a lower suicide rate, as well (Chandler & Lalonde, 2008; Taylor & Kalt, 2005).

MYTHS AND FACTS ABOUT AMERICAN INDIANS AND ALASKA NATIVES

Myth: All American Indians and Alaska Natives have a distinctive physical appearance that you can use to identify them.

Fact: Given the diversity among tribes after centuries of intertribal and interracial marriage, there are no distinguishing features that identify American Indians and Alaska Natives.

Myth: Most American Indians and Alaska Natives live on reservations.

Fact: About 22 percent of American Indians and Alaska Natives live on reservations or on trust lands off-reservation, according to the HHS Office of Minority Health (2018). Another 60 percent live in urban areas.

Myth: Gambling casinos are making many American Indians and Alaska Natives wealthy.

Fact: Fewer than half of the federally recognized tribes operate gaming facilities. Most profits from gaming go to improve a broad range of tribal services, and only about one-quarter of tribes with gaming give direct payments to tribal members. The size of those payments varies considerably, but in most cases it is only a small supplement. Several smaller tribes account for a disproportionate share of revenues that are dispersed to individuals (Kalt et al., 2008).

Myth: All Alaska Natives are Eskimos.

Fact: The U.S. government recognizes more than 200 tribes in Alaska. The Alaska Native Heritage Center identifies 11 distinct cultures. The Unangax and Alutiiq, who occupy the Aleutian Islands, were affected most heavily by contact with Russian explorers and adopted elements of their religion, cuisine, and language. Their life around the oceans makes their lives and livelihoods very different from inland cultures, such as the Athabascans, who have traditionally migrated with the seasons, and the Inupiaq and St. Lawrence Island Yup'ik of the far North. In some areas, the term “Eskimo” is considered derogatory.

Myth: American Indians and Alaska Natives have an innate, unquenchable appetite for alcohol and become extremely violent when they consume too much.

Fact: When Native Americans were first exposed to alcohol in the 18th and early 19th centuries, some abstained, and others drank in moderation. They did not display an immediate craving for alcohol. No evidence suggests that American Indians and Alaska Natives uniformly respond violently to being inebriated.

Myth: American Indians and Alaska Natives are more susceptible to the effects of alcohol than are people of other races.

Fact: This has no basis in science. Genes that increase the risk of substance use disorder and related factors, such as tolerance and craving for alcohol, are no more common among Native Americans than among White Americans. This myth deflects attention from the historical context of the introduction of alcohol into native communities by European traders and explorers and the effects of historical trauma.

Myth: The solutions to problems in native communities—alcohol abuse in particular—have to come from outside those communities.

Fact: The most successful substance abuse treatment programs have originated within native communities and use local models of recovery. This allows clients to link their health and well-being to that of the community. The myth serves to perpetuate the dominance of the mainstream culture and a patronizing attitude.

Myth: American Indians and Alaska Natives receive a lot of services at no cost, such as education and health care.

Fact: A safety net of local, state, and federal tax dollars helps maintain educational and healthcare institutions in native communities, just as it contributes to other economically impoverished areas. Regarding education, about 93 percent of more than 600,000 Native American students attend public schools, which are supported by local, state, and federal funds. About 42,000 students attend 183 Bureau of Indian Education schools, most of which are tribally controlled.

A combination of Medicaid, IHS funding, state and local funds, federal discretionary grants, and tribal funds pays for behavioral health services for American Indians and Alaska Natives. Individuals may be eligible for funding from some or none of these sources. About 2 million people from federally recognized tribes and 34 urban Indian communities (of the 5.2 million who identified as Native American in the 2010 Census) received health care from IHS over a 3-year period (IHS, 2011). Increasingly, tribes have contracted for behavioral health services, which they operate themselves.

Myth: American Indians and Alaska Natives are honored by American Indian mascots.

Fact: These portrayals are coarse stereotypes. Although some depictions may be less offensive than others, they are all caricatures that obscure the uniqueness of the individuals who make up the population. Most American Indians and Alaska Natives are offended by these mascots.

The Economic and Social Conditions of American Indians and Alaska Natives

As you know, the lives of American Indians and Alaska Natives vary widely, but Native Americans are more likely than members of other racial or ethnic groups to face economic hardships and social problems. Many of these problems likely contribute to behavioral health issues among American Indians and Alaska Natives.

Income and poverty

Poverty is a significant and consistent variable across all social conditions that American Indians and Alaska Natives face. According to the Census Bureau (2018), 25.4 percent of American Indians and Alaska Natives were living in poverty, compared with 13.4 percent of the total population. American Indians and Alaska Natives had a median household income of $41,882, compared with $60,336 for the population as a whole. The percentage of American Indians and Alaska Natives living in poverty was even higher in some states—as high as 51 percent for native households in South Dakota. Research with a variety of populations, including American Indians and Alaska Natives, suggests that poverty can contribute to the development, persistence, and severity of some mental and substance use disorders.

Unemployment

Unemployment is high among American Indians and Alaska Natives; in 2017, 7.8 percent were unemployed, compared with 3.8 percent of White Americans (Department of Labor, Bureau of Labor Statistics, 2018). Four years earlier, the American Indian and Alaska Native unemployment rate had been above 10 percent for 5 consecutive years (Austin, 2013). The unemployment rate is even higher for Native Americans living on reservations and other tribal lands (Pettit et al., 2014). In 2010 there were numerous states (which included Alaska, Arizona, California, Maine, Minnesota, Montana, New Mexico, North Dakota, South Dakota, and Utah) where fewer than 50 percent of Native Americans ages 16 and older living on or near reservations were employed (Department of the Interior, Office of the Assistant Secretary–Indian Affairs, 2014). This included people out of the labor force. Unemployment is associated with an increased risk for substance abuse for American Indians and Alaska Natives, and it may contribute to other behavioral health problems.

Fewer than half of all American Indian and Alaska Native women who experience violence report the crime to police. Of those who report, an estimated 60 to 90 percent of cases are not prosecuted. Native women who experience violence and live on reservations or in villages face the greatest barriers in obtaining prosecution because of jurisdictional conflicts, lack of jurisdiction, and limited tribal criminal justice funding.

Sources: Amnesty International, 2006; Bachman et al., 2008.

Housing and homelessness

American Indians and Alaska Natives have a high rate of homelessness. In 2017, 3 percent of people entering homeless shelters were Native Americans, although they made up less than 2 percent of the population (Henry, Watt, Rosenthal, & Shivji, 2017). American Indians and Alaska Natives who have houses are also more likely than the general population to live in overcrowded conditions or to lack kitchen facilities or complete plumbing (Pettit et al., 2014). In part, this crowding may occur as a result of accepting relatives into the household who may not have housing. For more comprehensive information on homelessness, see TIP 55, Behavioral Health Services for People Who Are Homeless (SAMHSA, 2013a).

Education

Compared with the general population, American Indians and Alaska Natives are less likely to graduate from high school or to have an equivalency, bachelor's, or advanced degree (Ogunwole, 2006). Education protects against substance abuse, depression, suicidality, and other behavioral health problems for American Indians and Alaska Natives, as well as for other populations.

Trauma

Compared with members of other major ethnic or racial groups (i.e., African Americans, Asian Americans, Latinos, White Americans), American Indians and Alaska Natives are more likely to suffer from many different types of trauma. Rates of trauma exposure are especially high for American Indian and Alaska Native women, relative to women in the population as a whole (Manson, Beals, Klein, Croy, & AI-SUPERPFP Team, 2005).

Higher rates of certain types of trauma exposure (e.g., car accidents, unintentional injuries from other accidents) are related to the fact that many American Indians and Alaska Natives live in rural areas, where they may engage in more outdoor activities and have poorer infrastructure (e.g., bad roads, greater driving distances). High rates of binge drinking and other substance abuse can also increase risk for accidents. There are fewer hospital facilities on native lands, so accidents are more likely to be fatal; American Indian and Alaska Native people are about two and a half times as likely to die from unintentional injuries as are members of the general population (IHS, 2017). Socioeconomic conditions, health disparities, and racism that contributes to violence against American Indians and Alaska Natives affect other types of trauma.

Different types of trauma exposure are associated with increased risk for a number of different behavioral health issues (see Ehlers, Gizer, Gilder, & Yehuda, 2013). For more information on the links between trauma and mental and substance use disorders, see TIP 57 (SAMHSA, 2014b).

Violent crime

American Indians and Alaska Natives are more likely to experience violent crime than are members of any other major racial or ethnic groups—about twice as likely to experience it than African Americans, 2.5 times more likely than White Americans, and more than 4.5 times as likely as Asian Americans (Perry, 2004). What may be even more remarkable is that, compared with every other major racial or ethnic group, Native Americans are more likely to experience violence from members of other racial or ethnic groups and are more likely to experience violence from strangers (Harrell, 2012). Native women are more likely than members of any other major racial/ethnic group to be survivors of rape. Acts of sexual violence against American Indian and Alaska Native women are mostly committed by members of other races. A recent report showed that, among American Indian and Alaska Native victims of sexual violence, 96 percent of women had experienced sexual violence by non-natives, whereas only 21 percent reported sexual violence by other Native Americans (Rosay, 2016). At the same time, arrest rates for most other crimes among American Indians and Alaska Natives are comparable to those for the general population (Department of Justice, Federal Bureau of Investigation, 2018).

BEYOND TRAUMA: SOUTH DAKOTA URBAN INDIAN HEALTH

South Dakota Urban Indian Health (SDUIH) provides holistic health and behavioral health services by integrating traditional ways into its treatment programs. SDUIH created a culturally specific recovery group called Beyond Trauma in response to community need. Beyond Trauma recognizes that many substance use disorders in the American Indian community stem from historical, childhood, and ongoing trauma. The program holds that addressing trauma is crucial to support ongoing recovery and improve the quality of relationships with self, family, and the community—a key ingredient in recovery. The Beyond Trauma support group helps participants “create rewarding and enjoyable lives, beyond a survivor identity” (p. 10). The group opens with a prayer and smudging. Then, participants share their challenges and celebrate how they have overcome those challenges. Participants develop strong, trusting relationships with one another. The recovery group is also an opportunity to forge lasting relationships and share substance-free activities with others in the community. One key benefit of Beyond Trauma is the opportunity for participants to see resilience in their peers and then, through self-reflection, begin to recognize it in themselves.

Source: Urban Indian Health Institute, 2014.

Child abuse

Abuse and neglect in childhood are associated with increased risk for substance abuse, anxiety disorders, and mood disorders. Research conducted with American Indians and Alaska Natives confirms this link (e.g., Libby, Orton, Novins, Beals, & Manson, 2005).

Rates of childhood abuse among American Indians and Alaska Natives vary considerably among tribes, and different studies have found widely different rates. Native children continue to be overrepresented in the child welfare system, with higher rates of reported child maltreatment compared with other racial and ethnic groups. One study also found that American Indian and Alaska Native children were more likely to die from abuse than were White American or African American children (Dakil, Cox, Lin, & Flores, 2011).

Domestic violence

American Indian and Alaska Native men and women are more likely to report having experienced domestic violence than are men and women from other racial/ethnic groups (Breiding, Chen, & Black, 2014). As with other types of violent crime, non-Native Americans commit the majority of domestic violence toward Native Americans.

Having experienced domestic violence has been associated with binge drinking and other types of substance abuse for American Indians and Alaska Natives (Oetzel & Duran, 2004), and severe intimate partner violence has been associated with increased risk for mood disorders and anxiety disorders for American Indian and Alaska Native women (B. Duran et al., 2009). (See also TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women [Center for Substance Abuse Treatment, 2009b].)

Physical health

American Indians and Alaska Natives are more likely than other racial or ethnic groups to have certain physical problems, including tuberculosis, diabetes, and cardiovascular disease (National Center for Health Statistics, 2014). They are also more likely to report current health as only poor to fair. Mortality rates from many causes are higher for Native Americans than for the general population. Death rates are higher related to alcohol (520 percent higher), diabetes (177 percent higher), chronic liver disease and cirrhosis (369 percent higher), and tuberculosis (450 percent higher) than for the general population (IHS, 2014).

Many health problems in American Indians and Alaska Natives have a behavioral component. Seven of the 10 leading causes of death for Native Americans have a behavioral component and relate to lack of exercise, poor diet and nutrition, tobacco use, or alcohol use (Kochanek, Murphy, Xu, & Tejada-Vera, 2016).

A lack of access to quality health care also contributes to American Indians' and Alaska Natives' poor health. Although most Native Americans live in urban areas, IHS provides care at a limited number of urban sites, and these sites receive only a small percentage of IHS funds. Thus, even American Indians and Alaska Natives who are eligible for IHS services may not have access to a program. Moreover, IHS offers services only for members of federally recognized tribes, which excludes nearly two-thirds of American Indians and Alaska Natives. Many American Indians and Alaska Natives who do not receive IHS services lack medical insurance and may not seek medical care because they cannot afford it (Urban Indian Health Institute, 2008).

THE ROLE OF CULTURE IN BEHAVIORAL HEALTH SERVICES

As a treatment provider, you will want to help your clients be as healthy as possible and lead a balanced and meaningful life. To do so, you need to understand how a client defines health, balance, meaning, and similar constructs, as well as the specific culture or cultures that are relevant for each client. Many American Indian and Alaska Native cultures share certain values and beliefs; however, what is important for one person or community may differ from another individual or tribe. And, as with any racial, ethnic, or cultural group, differences exist within the same community among members.

For many American Indians and Alaska Natives, the process of healing a mental or substance use disorder will involve reconnecting with their traditional culture, although for others, it may involve distancing themselves from some cultural activities that were connected with substance abuse. Researchers have found that a stronger connection to one's traditional native culture or to certain parts of it (such as spirituality) can be a protective factor against some mental and substance use disorders, although other variables such as gender and place of residence affect this as well. Reconnecting clients with their traditional culture may, depending on the clients' preferences, also aid in the treatment of those disorders. (See the West section discussion of traditional healing and other cultural practices in behavioral health services.)

The Importance of American Indian and Alaska Native Culture to Your Clients

To determine the widely varying role of American Indian and Alaska Native culture in your clients' lives, you will need to discuss it with and assess each client. Some associate very strongly with their traditional native culture, whereas others consider themselves to be members of mainstream American culture and have little or no connection to native culture. Still others have high acculturation to another nonmainstream culture while maintaining a connection with their tribal culture. Many American Indians and Alaska Natives are multicultural, and they are able to successfully navigate among cultures including mainstream culture.

The process whereby a person from one cultural group learns and adopts another culture is called acculturation. If an individual fully adopts another culture, it is called assimilation. An individual who practices biculturalism is considered to be equally fluent in both his or her culture of origin and mainstream culture. This is often referred to as “walking in two worlds” among American Indians and Alaska Natives. “Enculturation” is a term describing the process by which one learns about a culture. It often describes an individual's knowledge of and connection with his or her traditional culture (Stone, Whitbeck, Chen, Johnson, & Olson, 2006).

Exhibit 1.1-3 shows a sample cycle of assimilation and reconnection of native cultural identity, beginning with traditional native identity and proceeding to reconnection.

Box Icon

Box

EXHIBIT 1.1-3. Cycle of Assimilation and Reconnection.

Acculturation is not a static process. At different points in time, individuals may be at different places on this continuum. It does not represent a hierarchy of values; there is no right or wrong place to be on this continuum. What is important is that clients feel comfortable with their levels of acculturation and not feel acculturative stress because of pressure to be one way or the other.

The East (right) side of the circle in Exhibit 1.1-3 indicates that some native people live traditional lives in traditional American Indian and Alaska Native communities. They may have little contact with non-Native Americans; they may speak only their own languages. They may engage in a subsistence lifestyle, although they may make use of modern technology, such as using snowmobiles instead of dogsleds when hunting. Their worldviews are very similar to those held by their people over centuries. People who are totally immersed in their indigenous cultures would be unlikely to seek treatment from outsiders. When they seek help, they will more likely work with traditional healers.

On the West (left) side of the circle are people who seldom think of their native culture and do not see it as a defining characteristic of who they are. They may recognize that they have native ancestry and even identify their race as American Indian or Alaska Native because of it, but they are very comfortable with mainstream culture, have mainstream values and worldviews, and do not feel that their native ancestry should play a role in their behavioral health services.

Most American Indians and Alaska Natives fall somewhere between these two poles. They may live away from their tribal lands at least part of the time. If they live in a city, they may be active in an American Indian and Alaska Native community center and participate in traditional ceremonies, pow wows, and other native cultural gatherings on weekends or during vacations. They may socialize with other natives as well as non-Native Americans. Some know their tribal language and speak it at home, but most do not, although they may wish they had learned it. They consider themselves bicultural (South).

The North (upper portion) of the circle represents reconnection, thus completing the cycle. Many American Indians and Alaska Natives are making a conscious effort to reconnect with native ways. They are reconnecting and investing in developing a native identity. This may include reengagement of tribal-specific or pan-Indian cultural activities.

Consider this circle for a moment in regard to your own ethnic heritage. How important are the cultures of your ancestors? How do those cultures affect you?

Commonalities Among American Indian and Alaska Native Cultures

Despite the diversity among American Indian and Alaska Native cultures, similarities among them provide common ground. Some beliefs and values are shared by most American Indian and Alaska Native cultures and are distinct from those of mainstream American culture. These are beliefs that are likely to be held by American Indians and Alaska Natives who at least partially associate themselves with native cultures, although for those who are fully acculturated to mainstream American culture, even these broad beliefs may not be relevant.

The American Indian and Alaska Native worldview

The way American Indians and Alaska Natives look at life and the world around them—their worldviews—differ vastly from those of mainstream Americans. Europeans who came to this country believed that the earth and its creatures should serve their needs. American Indians and Alaska Natives believe that they are only one part of creation, dependent on nature, and meant to live in harmony with all things—not just people, but also animals, plants, and the elements. Native traditions teach that all these things have life and deserve respect. Native Americans also traditionally believe in the importance of balance and harmony at all levels of life: internally for the individual, socially among people, and naturally in relationships with animals and the rest of creation. This worldview continues to influence American Indians and Alaska Natives.

ALASKA NATIVE VALUES

Alaska Native cultures have certain values that are of paramount importance to their members. Below are some values that the five major Alaska Native cultures share, although there may be some minor variations among them.

Show respect to others: Each person has a special gift.

Share what you have: Giving makes you richer.

Know who you are: You are a reflection on your family.

Accept what life brings: You cannot control many things.

Have patience: Some things cannot be rushed.

Live carefully: What you do will come back to you.

Take care of others: You cannot live without them.

Honor your elders: They show you the way in life.

Pray for guidance: Many things are not known.

See connections: All things are related.

Source: Alaska Native Knowledge Network, 2006.

The importance of community for American Indians and Alaska Natives

Native cultures are more community oriented than mainstream American culture and less concerned with the importance of individual efforts and privileges. American Indians and Alaska Natives define themselves as members of a family, community, tribe, and nation. Native cultures are most strongly maintained by those living in an Alaska Native village or on tribal lands, but those who live some distance from those lands may still identify strongly as members of a tribe.

Community norms and values play an important role in all aspects of life for American Indians and Alaska Natives, including treatment for and recovery from mental and substance use disorders. Involving family and community members in treatment is important in providing effective services for most American Indians and Alaska Natives. When you provide services in a location that is predominately Native American, you will want to elicit input from community members on how services are rendered and what types of services are needed. However, keep in mind that shame concerning behavior or treatment-seeking related to substance use or mental illness can also affect your American Indian and Alaska Native clients, who may be wary of seeking services because of what others in the community may think.

American Indians and Alaska Natives typically value connectedness and personal relationships. Your interest in the community and in building relationships with community members can help them accept you as a provider and your program. Individuals may be more willing to seek your services and have a more positive experience in treatment. By not limiting your involvement in the community to the treatment milieu but also engaging in the cultural, social, and recreational activities of the community, you will better understand how life there functions.

Family structure

The family is extremely important to American Indians and Alaska Natives, and native families differ in some ways from the mainstream American norm. Some native societies are matrilineal in social organization and descent. This means, in part, that families may trace their ancestral lineages through the maternal side, pass property through female heirs, grant women key decision-making roles in governance, and readily assign custody to mothers or grandmothers. American Indians and Alaska Natives typically define family as extending beyond the nuclear unit, sometimes including people who are not blood relations. About half of American Indian and Alaska Native family households include members of the extended family, and about one-quarter include people who are not directly related to the primary residents. About 30 percent of American Indian and Alaska Native families are headed by single mothers. Grandparents also often raise children, sometimes with assistance from other members of the extended family.

Because extended families are often very close, you may find that they expect to be involved in the treatment process along with their loved ones. Grandparents, aunts, uncles, cousins, and “adopted” family members who are not blood relatives may play important roles. It is important for you to ask your clients about their families and their willingness to be involved in treatment. You can ask new American Indian and Alaska Native clients questions such as, “Where did you grow up?” “Who raised you?” or “Who are the members of your family?”

American Indian and Alaska Native spiritual beliefs

American Indians and Alaska Natives observe many spiritual practices. Although these spiritual practices reflect diverse, specific beliefs about such things as the creation of the world or the appropriate ceremonies to perform at given times, many share certain basic spiritual principles. These involve living in harmony and balance with others and with the world, believing that there is order to the universe, and feeling a connection with others and with all life.

Spirituality is important for most American Indians and Alaska Natives. For example, 79.2 percent of American Indians and Alaska Natives ages 12 to 17 in 2014 stated that religious beliefs are an important part of their lives, and 72.3 percent believed that their beliefs shape decision making (Center for Behavioral Health Statistics and Quality, 2015). Having a stronger commitment to traditional spirituality is a protective factor against suicide and some mental and substance use disorders for American Indians and Alaska Natives (Eastman & Gray, 2011; Garroutte, Goldberg, Beals, Herrell, & Manson, 2003).

Many American Indians and Alaska Natives are Christians, although many belong to groups that incorporate some native beliefs and practices into Christianity, such as the Native American Church. Less than 0.3 percent of the U.S. population (about one-sixth of the Native American population) identify as practicing traditional Native American religions (Pew Forum on Religion & Public Life, 2008). Still, even among American Indians and Alaska Natives who identify solely as Christian, traditional native spiritual beliefs may affect their view of the world and their place in it. In some native communities, both Christian and native ceremonial rituals occur at the same time (e.g., taking first communion and wearing regalia, smudging at baptisms).

The Navajo concept of hozhq is used in everyday speech to express one's interconnectedness with other people and the land, balance, and harmony in one's life—elements that are part of one's health and happiness. For example, when someone is leaving another individual, the person may say, hozhqqgo naninaa doo: “May you walk about according to hozhq.” In part, it is a reminder to go about deliberately.

Source: Witherspoon, 1977.

What You Need To Understand About the American Indian and Alaska Native Experience Today

American Indians and Alaska Natives are, genetically or by adoption, members of a community that has experienced centuries of assault on their culture and still survives. To the extent that your American Indian and Alaska Native clients have been connected to native family and community, they know this history, and it likely continues to affect them. They also probably have a strong positive connection with their people and the place from which they come. American Indians and Alaska Natives today are more likely than members of other groups to face a host of problems, including poverty, unemployment, trauma, criminal victimization, physical health problems and disparities, and mental and substance use disorders. However, they continue to be a resilient people who can draw on the strength of their cultures, communities, and families to help face these problems.

“Realize that we as human beings have been put on this earth for only a short time and that we must use this time to gain wisdom, knowledge, respect, and the understanding for all human beings since we are all relatives.”

—Cree proverb

Source: Saskatchewan Indian Cultural Center, 2014.

Moving to the South: The Direction of Cultural Awareness and Competence

Because you are reading this TIP, you must already be concerned about cultural competence. If you want to know more about treating clients from American Indian and Alaska Native cultures, you need to make some changes in your practice to best meet their needs, and that means you recognize a need for cultural competence.

Cultural competence is important for all clients, but this section discusses how your cultural competence can affect your treatment of American Indian and Alaska Native clients specifically and how you can build cultural competence when working with those clients. Sections that follow investigate how your cultural competence in relation to native ideas of health and healing can positively affect treatment (the West) and how cultural competence can help you tailor and implement treatment and prevention services for mental illness and substance abuse to make them appropriate for your American Indian and Alaska Native clients (the North). TIP 59 (SAMHSA, 2014a) has a more detailed discussion of how to provide culturally responsive treatment for all clients and includes information on assessing your own cultural identity, models of cultural identity development, and core competencies for providers related to this topic.

You develop cultural competence in stages, starting with cultural awareness, which is itself a three-stage process. If you have cultural awareness, you will examine how your own beliefs, experiences, and biases affect your definitions of normal and abnormal behavior, behavioral health, and recovery from behavioral health problems. After developing awareness, you will need to expand your knowledge of American Indian and Alaska Native cultures, then work on applying that knowledge to your practice. You can also work to ensure that the organization that employs you takes cultural competence seriously and builds its own organizational cultural responsiveness, a topic discussed at greater length in Chapter 4 of TIP 59 (SAMHSA, 2014a).

Developing Cultural Awareness

Three steps are involved in developing cultural awareness. Becoming aware of cultural differences is the necessary first step. The second step is gaining awareness of your own cultural values and the role they play in your life. The third step is developing an understanding of cultural dynamics, such as cultural barriers, prejudice, and racism, which may occur when members of diverse cultures interact.

Step 1: Awareness of cultural differences

The first step in providing culturally responsive treatment, no matter what the population, is to become aware of the differences between the culture with which you identify and that of your clients. Once you do so, you will better understand how your clients' cultures may affect them and how your culture affects your interactions with people from other cultures.

“We are social beings; as Alaska Natives we possess a strong history of successes through unity and togetherness. We feel a need to belong. A danger in not knowing who you are is the attraction to be somebody else.”

—Students of the Gaalee'ya Project

Source: University of Alaska Fairbanks, 2013, p. 5.

Your American Indian and Alaska Native clients are probably already aware of the differences between mainstream American cultures and native cultures. They have likely had to negotiate these differences all their lives. As noted in the discussion of acculturation, most American Indians and Alaska Natives are somewhat acculturated to mainstream society while also being at least somewhat comfortable with their traditional cultures. However, even the most traditional American Indians and Alaska Natives will be exposed to mainstream culture sometimes, whereas most mainstream Americans will have little contact with Native American cultures. This means that you will likely have a lot more to learn about American Indian and Alaska Native cultures than Native American clients will have to learn about mainstream American culture.

If you are completely enmeshed in mainstream American culture, it is easy to assume that your values are the norm. You may not be aware of how other cultures define values and beliefs because you assume that everyone naturally shares your values and beliefs. In some cases, you may even consider signs of straying from that norm as symptomatic of mental illness, even though that behavior may be perfectly acceptable within your clients' cultures (e.g., a client who has had visions during a sweat lodge or another ceremony might be considered psychotic in mainstream culture).

When you lack cultural awareness, you may make assumptions based on the attitude that your American Indian and Alaska Native clients are pretty much the same as you are—or that they should be if they are to recover from their problems. Without cultural awareness, you more easily discount the importance of how culturally defined beliefs, values, and attitudes influence your impressions of clients and the treatment plans you formulate with them.

Some practitioners assume that all Native American clients have difficulty in making eye contact. This preconception can oversimplify your clients' behavior and often overshadow the need to explore other explanations if they are quiet, take time to respond, or are looking away. Be overly cautious of stereotypes. Your clients have many sound and historical reasons for being wary of treatment. Your responsibility is to be trustworthy and to take the time needed to build trust and to invest in relationships.

Of course, your cultural identity may differ from that of mainstream society. Your family may be immigrants or come from a culture within the United States that has values that differ from the mainstream. In that case, you are probably further along in the process of becoming culturally aware and have already thought about your own cultural identity and its relationship to mainstream American culture. Still, even in those cases, you must be careful not to assume that the experiences of a Native American negotiating these cultural differences are the same as the experiences of those in your own cultural community. American Indians and Alaska Natives have a unique history and face unique challenges in their interactions with mainstream culture and its institutions. Even if you have worked with American Indian and Alaska Native clients before or have a cultural connection of your own to American Indian and Alaska Native cultures, you may still not understand the specific culture of an individual American Indian and Alaska Native client. You will want to keep in mind the diversity of American Indian and Alaska Native cultures and remember that acceptable practices in one culture may not be acceptable in another.

One way to begin noticing cultural differences is becoming conscious of how your own culture shapes your beliefs, values, perceptions, and behavior. Observe your reactions to American Indian and Alaska Native clients' responses and presentation and take time to look at how their cultural, linguistic, and historical experiences may differ from your own; do not assume that every individual from the same cultural group will respond the same way. It is a delicate balance—being aware that culture plays a significant role while avoiding generalizations and allowing for individual differences.

Step 2: Self-assessment of your values

The next step in becoming culturally aware is to look at how your culture affects your beliefs and values. Your culture may be tied to your racial or ethnic identity, or you may identify with mainstream American culture, in which case that culture will help define your beliefs and values. Your culture will shape other things too: perhaps the music you listen to, the food you eat, the holidays you celebrate, the religious or spiritual beliefs you have, your choice of occupation, and the way you spend your leisure time. It will influence your attitudes toward authority, health and wellness, and behavioral health services. Your cultural identity is unlikely to be static, and even the act of becoming aware of your cultural beliefs can cause some change to those beliefs, or at least an openness to changing them.

One way to evaluate how culture affects your beliefs is to look at some beliefs and values common to most, if not all, American Indian and Alaska Native cultures and consider how your beliefs may be similar or different. Exhibit 1.1-4 lists eight cultural values and offers possible explanations as to why these values became important for native societies and how they affect behavior. As you think about these, also think about how your own beliefs and values may differ. It is not a matter of judging one value as right and the other as wrong, but rather, improving your understanding of American Indian and Alaska Native values and beliefs as well as your own.

Box Icon

Box

EXHIBIT 1.1-4. Traditional American Indian and Alaska Native Values and Beliefs.

Step 3: Understanding the effects of cultural differences

After examining just these few cultural differences, you can see the potential for misunderstanding and miscommunication in relationships with American Indian and Alaska Native clients. If you do not understand American Indian and Alaska Native cultures, you might easily mistake modesty and humility for a lack of engagement or a lack of interest in working to acquire wealth as being unmotivated or lazy.

Such misunderstandings feed prejudice, discrimination, and microaggressions at a societal level and in treatment. The third part of developing cultural awareness is understanding how cultural differences can result in prejudice, stereotyping, and racism. Within the treatment setting, this involves evaluating how cultural differences can create misunderstandings that in turn lead to inadequate treatment for American Indian and Alaska Native clients. This is not an easy topic to explore; it requires that you also look at ways in which you and your organization may have discriminated or been biased against people from a culture that is different from your own.

Your American Indian and Alaska Native clients' priorities, values, and styles of communication may differ from yours. Their reasons for seeking healing may be different from what you have experienced before. Their goals may be different from what you expect, and their behaviors in your treatment setting may differ from what you ask of them. You may be frustrated when clients seem slow to open up, arrive late or not at all for sessions, do not speak up in group discussions or group therapy, do not look you in the eye, and evade answering your questions.

But what about the American Indian and Alaska Native clients' frustrations? From their point of view, the provider may seem uninterested in understanding them. He or she may seem to think that a diagnosis—labeling a person—is the important thing, not the individual. The provider, or the program, is full of advice based on that label and tells the client what he or she should do, as if the client were a child and not capable of reaching his or her own conclusions. The provider seems rude, taking notes, completing paperwork first, or looking directly at the client in a manner that seems disrespectful and sometimes challenging or intrusively intimate. The provider asks a question but is too impatient to wait for the client to think carefully about what is a true and important response. In the group sessions, not only do others give the client advice, but they also expect the client to give advice to others, which is not how one shows respect to others. Much of what typically occurs in treatment may be offensive or at least strange to an American Indian or Alaska Native client.

WHAT ARE MICROAGGRESSIONS?

Microaggressions are brief, everyday slights, insults, snubs, derogatory statements, or indignities that communicate hostility or negative, judgmental messages to a person in a marginalized group based on his or her race, ethnicity, religion, nationality, sexual orientation, gender expression, gender identity, disability, age, socioeconomic status, or other identity characteristics. Microaggressions may be intentional or unintentional, conscious or unconscious, or verbal or nonverbal acts or environmental cues. Racial microaggressions are a subtle form of racism based on stereotypes of a specific racial or ethnic group. Examples of microaggressions perpetrated against American Indian and Alaska Native people include Indian mascots in high school, college, and professional sports; a White supervisor at work jokingly calling an American Indian subordinate “Chief”; a teacher in a mainstream class singling out an Alaska Native student to stop being so quiet and speak up; or a non-native behavioral health service provider diagnosing an American Indian client with a social anxiety disorder because he has difficulty maintaining eye contact.

Microaggressions have harmful consequences, including damaging the mental health of recipients; exacerbating the psychological effects of historical trauma; contributing to health problems; creating a hostile work or school environment; promoting and perpetuating stereotypes in the broader society; and contributing to the creation of inequities in education, employment, and health care. When providers are unaware of their prejudices and biases toward American Indians and Alaska Natives, their acts of microaggression can damage the therapeutic relationship, increase the premature termination of treatment, and significantly affect treatment.

Source: Sue et al., 2007.

Culturally responsive behavioral health agencies that serve American Indian and Alaska Native clients adapt to best fit the needs and preferences of those clients. This does not mean that you have to ignore problems, but rather, you need to find a way to address them that will not alienate your American Indian and Alaska Native clients. This is an ongoing process of learning for you, and beginning that process is the next step in developing cultural competence.

Next Steps in Developing Cultural Competence

After building cultural awareness, you will want to further expand your cultural competence by improving your knowledge of American Indian and Alaska Native cultures. Then, you will look for ways to apply that knowledge, using your knowledge of these cultures to frame treatment-related issues in an appropriate manner, adapt treatment strategies and interventions to be culturally appropriate, and develop new ways to provide services for your clients (e.g., through working with American Indian and Alaska Native traditional healers). You will need to regularly reassess your knowledge and your program so that changes can be made to improve the cultural relevance of your services. A helpful acronym for understanding how your knowledge of native cultures (or any cultures, for that matter) can assist in treatment is given in the box that follows.

RESPECT: A MNEMONIC FOR CULTURALLY RESPONSIVE ATTITUDES AND BEHAVIORS

Respect: Become familiar with communication styles. Understand how respect is shown in American Indian and Alaska Native cultures and show respect through verbal and nonverbal communications. Learn to listen. Be comfortable with silence and never interrupt or point with your fingers in conversations.

Explanatory model: Devote time to understanding how clients perceive their presenting problems, how these problems are understood in American Indian and Alaska Native cultures, and how healing takes place. Be respectful of traditional approaches to healing.

Sociocultural context: Recognize how tribal affiliation, culture, language, gender, gender roles, education, socioeconomic status, sexual and gender orientation, community, family, social organization (e.g., matrilineal), geographic location, and so forth affect treatment.

Participation: Appreciate that clients may have different expectations about treatment. Take time to understand your clients' perspective and attitudes toward treatment. Discuss the clients' expectation of roles.

Empathy: Express, verbally and nonverbally, the significance of your clients' concerns so that they feel you understand. If possible, share some of your own experiences.

Concerns and fears: Elicit clients' concerns and apprehensions about entering a treatment setting and about the behavioral health system.

Therapeutic alliance/Trust: Commit to behaviors that enhance the therapeutic relationship; recognize that trust is not inherent but that you must earn it. Native clients are likely to place more importance on who you are, rather than what you accomplished, in determining their level of trust in you.

Sources: Bigby & American College of Physicians, 2003; Campinha-Bacote et al., 2005.

Improving Your Knowledge of American Indian and Alaska Native Cultures

You can use a number of ways to improve your grasp of American Indian and Alaska Native cultures, and it is best if you try to make use of all of them. You can learn through reading, attending trainings and seminars, listening to other providers who work with this population, and, most importantly, talking with your clients and other American Indians and Alaska Natives.

Native people can tell you a lot about their cultures, either directly through their responses to questions about their cultures or indirectly through observation both in and out of the treatment setting. You can also talk to other American Indians and Alaska Natives in the community to clarify what you hear from your clients and evaluate it sensibly (e.g., do not assume that the client who engages in binge drinking is speaking for the community when he says that such drinking is acceptable). Working with traditional healers or elders (discussed further in the North section) or identifying a community member who is willing to serve as a cultural consultant are two ways to develop relationships with American Indians and Alaska Natives who are not clients. It also can be helpful for you or your program to become involved in community activities beyond the treatment setting.

To many American Indians and Alaska Natives, mental and substance use disorders do not only affect clients who enter the doors of your treatment center; they affect the entire native community or communities to which those clients belong. By engaging in activities in these communities, you and your program can improve your standing with them and begin to enlist their aid in promoting the recovery of your clients, as well as improving your understanding of your clients' cultures. This involvement may take the form of behavioral health-related community education and prevention services, which are a natural extension of treatment services. However, other types of engagement, such as in community recreational and cultural activities, can also be helpful.

Applying Your Knowledge to Behavioral Health Services

As you learn about your clients' cultures, you can practice applying that knowledge in different ways that will help you improve your interactions with American Indian and Alaska Native clients. You will learn what is appropriate and inappropriate as far as behavior is concerned, which sorts of interactions are likely to elicit positive responses, and which will elicit negative responses from your clients. Communication styles and the use of personal space are culturally defined, and by learning about them, you can make your communications with American Indian and Alaska Native clients more effective. For instance, both research and clinical experience suggest that they respond poorly to providers who try to instruct them on how to behave. They respond well to providers who share their own experiences, use stories, and give examples of how behavioral changes have helped in their own lives, provided the sharing is not excessive.

You will also learn how American Indian and Alaska Native cultures affect behavior in and out of the treatment setting and how cultural beliefs and values can be used to help create positive behavioral changes. Knowing about the socioeconomic and political forces at work in native communities and about Native American history will further help you understand the mental and substance use disorders that affect these communities.

Improving Your Cultural Competence

You will need to continually reevaluate your knowledge of American Indian and Alaska Native cultures and your skills in interacting with clients from those cultures. This may involve correcting false impressions and learning new ways to apply knowledge in practice. You may learn that information that applied to clients from one native culture is not effective with those from another culture (see “The Importance of Knowing the Specific American Indian and Alaska Native Cultures of Your Clients” box for an example).

Several instruments are available to help you assess your cultural competence. These are discussed in TIP 59 (SAMHSA, 2014a) and Part 2, Chapter 2, of this TIP. Other resources are available online, including the Cultural Competence Health Practitioner Assessment from Georgetown University's National Center for Cultural Competence and the American Speech–Language–Hearing Association's Self-Assessment for Cultural Competence.

It is important to regularly reassess your own skills and knowledge, but you will also need the assistance of your program to evaluate the quality of care provided to American Indian and Alaska Native clients. Providing culturally responsive treatment should improve the quality of care and outcomes for these clients.

THE IMPORTANCE OF KNOWING THE SPECIFIC AMERICAN INDIAN AND ALASKA NATIVE CULTURES OF YOUR CLIENTS

This TIP emphasizes that not all native cultures are the same. For that reason, you need to learn about the specific culture or cultures of your American Indian and Alaska Native clients. As an example, consider the case of 12-Step groups. A common criticism by American Indians and Alaska Natives is that the groups place a great deal of importance on self-disclosure and confession, which are practices that run counter to many native beliefs concerning humility and appropriate public behavior. However, not all American Indian and Alaska Native cultures have problems with such behavior, and the case of the Coast Salish people is an important exception. This group of tribes traditionally lived on the coast of what is now Washington State and British Columbia in extended families of hundreds of people that did not have established leaders, but rather, reached group decisions democratically. The Salish had a tradition of public confessional dancing, and some later adopted the Shaker religion in which public confessions of “sin” were common. Given these traditions, the public confession aspect of 12-Step groups and the loose democratic organization of those groups may fit well with Salish culture, and Salish people in recovery from substance abuse have generally felt very comfortable with the practices of 12-Step groups.

Source: Jilek-Aall, 1981.

Continuing West: Cultural Perspective on Behavioral Health

As you may expect, traditional American Indian and Alaska Native views on health and healing are considerably different from the mainstream models of health, illness, and treatment with which you are probably very familiar. In the West section, you will find more information about American Indian and Alaska Native concepts of health and wellness, illness and disease, and medicine and healing. This section introduces traditional healing practices and the function of native healers, a topic much larger than can be fully addressed here. This section also addresses American Indian and Alaska Native preferences and beliefs about behavioral health and seeking out behavioral health services. Although the focus is on mental and substance use disorders, the division between physical and behavioral health is not one that is typically recognized in native cultures, so the section begins with a discussion of health in general before moving on to behavioral health.

Although the material that follows is useful, it is very general. You will benefit from further exploring the specific health and healing beliefs of the American Indian and Alaska Native cultures to which your clients belong. The Part 3 literature review (available online) summarizes some resources that may be of assistance. Talking to medicine men and women, healers, and spiritual guides from the cultures you work with would be especially helpful.

American Indians' and Alaska Natives' Concepts of Health and Illness

There is no single American Indian and Alaska Native view of health and healing. Even traditional native cultures differ considerably regarding specific beliefs about the causes of illness and how best to treat them. As discussed further below, most American Indians and Alaska Natives try to balance traditional and mainstream views of health and healing, and many will seek help from both mainstream providers and traditional healers.

Certain basic principles apply to health and illness as they are understood by most, if not all, American Indian and Alaska Native cultures:

Health is viewed holistically. American Indian and Alaska Native cultures rarely make a distinction among physical, mental, emotional, and spiritual health. One aspect of health is believed to affect the others; addressing a problem at one level may help heal problems at other levels. A holistic view also means that prevention and treatment are not divided but seen as part of the same process.

Illness affects an individual's community as well as the individual. The holistic view of health may also extend to the relationship between the individual and his or her community. A health problem that affects one person will have effects on a family, community, tribe, and other individuals as well. This also means that healing the community can positively affect individual health and that the process of healing may need to occur at the community level to be effective for the individual.

Being healthy means living in harmony and balance. Illness occurs when an individual is out of harmony, and healing is a process of restoring balance. This balance is both internal (affecting one's internal mental, physical, and spiritual state) and external (affecting one's relationships with all living beings). Another potential source of imbalance is cultural; American Indians and Alaska Natives may feel a loss of balance or harmony in trying to find equilibrium between the values of two cultures. This is one reason why healing may involve reconnecting with a traditional culture.

Illness may be purposeful or personified. An illness may be purposeful, in the sense that it occurs because an individual or a relative has broken some cultural taboo or natural law, which creates a state of disharmony and hence a state of illness. These violations may have occurred recently, in the past, or in a previous generation. Because of this, in some American Indian and Alaska Native cultures, a person may be held at least in part responsible for developing an illness, and the individual who has the illness may see it as his or her responsibility to bear the symptoms. An illness may also be personified in the sense that it has a spirit, and that spirit may need to be addressed as part of the healing process.

Be thoughtful about how you discuss presenting problems. Remember that your clinical training is influenced by the culture and common practices of mainstream health care. These practices can conflict with or be insensitive to American Indian and Alaska Native beliefs. Native people may see labeling an illness (i.e., giving it a name) as a naming ceremony that increases its power. Likewise, they may view discussing prognosis or consequences of a behavior or illness as a prediction or prophecy, believing that thought and language have the power to shape reality and the future.

Traditional medicine and healing

The traditional view of medicine and healing is significantly different from that of the mainstream healthcare system. Even the word “medicine” has a different meaning in American Indian and Alaska Native tradition. Medicine, in native cultures, is the essence of being or spirit that exists in everything on Earth (Garrett, 1999). Medicine may be good or bad, depending on how it affects the individual. For example, it is good if it restores balance and harmony and bad if it disrupts balance and harmony. When counseling American Indian and Alaska Native clients with drinking problems, one provider suggests to clients that alcohol is medicine and that by taking it without proper knowledge, the drinker is practicing a form of witchcraft on himself or herself by consciously ingesting bad medicine (E. Duran, 2006).

Behaviors that mainstream providers might label as symptoms of mental illness may be seen among American Indians and Alaska Natives as the expression of special gifts (e.g., hallucinations, manic symptoms). Native peoples may also perceive physical conditions as sacred; for example, dementia may be viewed as a process or sign that the person's spirit has already crossed over into the next world. Although the body has remained behind as it prepares to leave, the person's spirit is already communicating in the spirit world, making it difficult for those left behind to understand the person's language and behavior. Therefore, caring for individuals who are transitioning may be perceived as sacred work.

Traditional healers may be referred to as “medicine men” or “medicine women,” but to avoid confusion among different meanings of “medicine,” this TIP refers to American Indian and Alaska Native “healing practices” rather than to “medicine.” However, terms such as “services” and “practices” may not make sense to some American Indian and Alaska Native clients, so when framing inquiries on the use of traditional healers, it is probably better to use the term “help-seeking.”

Traditional Native American healing is a body of wisdom for transforming illness into health through the integration of mind, body, emotion, and spirit. Traditional healing usually involves physical actions like participating in ceremonies or taking herbal remedies. Often, a whole family or community is involved in the healing process through group rituals. Traditional healing can benefit clients in a number of ways (see the “How Does Traditional Healing Work?” box).

In traditional healing, there is much less concern with diagnosis. Healers may have no specific label for a problem but will focus on what may have caused the problem (e.g., breaking a taboo, difficulties stemming from mainstream culture, social or relational conflicts) and what can be done to address it. In some American Indian and Alaska Native cultures, some illnesses or problems (e.g., alcohol dependence) may be recognized as outside or “White man's” problems that traditional healers cannot properly treat, instead requiring mainstream providers' attention.

HOW DOES TRADITIONAL HEALING WORK?

American Indian and Alaska Native healing practices typically involve community and serve to restore a sense of connection to tribe and culture.

Traditional practices often increase social support, thereby improving health outcomes.

Healing rituals improve participants' coping abilities and quality of life. Traditional healers are the keepers of stories with the tribal community. These stories represent themes and often serve to guide individuals on how to handle various problems.

Traditional healing helps individuals transcend their experiences by identifying the meaning and purpose of those experiences within the context of the community, including the environment.

Some traditional healing rituals alter participants' consciousness, which in turn can produce a spiritual transformation that affects overall health.

Part 3, the online literature review, has more information on traditional healing's effectiveness.

Traditional Healers

Traditional healers are people who were often recognized even as children as being empathic and having a gift for working with people to lessen their pain. If these talents are recognized in a youth, he or she might be taken as an apprentice by the tribe's traditional healer. If not, he or she will learn from other healers. Training goes on over many years. Some American Indian and Alaska Native cultures (e.g., the Navajo) have carefully defined ceremonies and practices for healing that need to be taught. Other native cultures (e.g., the Inuit) have traditions in which the individual healer must learn through visions and interactions with spiritual entities, and the practice of healing may vary among individual healers.

In urban areas, it may be difficult to find a traditional healer. Often, individuals have to travel far or go to the reservation to find healers with the same cultural traditions. Depending on tribal affiliation, traditional healers from other tribes may be accepted or rejected. It may depend on the historical relationships between tribes, individuals' beliefs and practices, and the traditional healer's willingness to work with individuals who are not members of the same tribe.

The healer does not have the same relationship to the client as a medical provider does, nor is healing something that just occurs in a specialized facility. A traditional healer will recognize that healing is not something that is done by one person to another, but involves participation by the individual, spiritual entities, family, and friends, as well as the healer. Traditional healing may be provided in the client's home, other homes or buildings in the community, or outside the community in a natural setting.

Traditional healers will often only work with members of their own tribe, but some may be willing to work with other Native Americans or even with people of other races. Most traditional healers are spiritual guides and practice traditional native spirituality. Some American Indians and Alaska Natives may not want to work with traditional healers because of religious differences. Christian traditions such as those associated with the Native American Church and the Pentecostal Church also provide healing rituals to American Indians and Alaska Natives. Traditional healing practices and beliefs may be expressed within a Christian context.

Generally, traditional healers do not charge fees for treatment but will accept gifts for services rendered and money for transportation, if needed. There is no official body that sanctions traditional healers, and there are fraudulent practitioners who claim to represent native traditions. As a provider, you should obtain recommendations of traditional healers from tribal members and leaders. If healers are accepted by their tribes' elders and community leaders, they can generally be expected to be authentic.

“Plastic shamans” is a term used for individuals who pose as traditional healers or spiritual leaders without any true affiliation to the traditions, healing practices, and culture that they claim to represent. Most often, but not always, they are non-native individuals who steal, misrepresent, and exploit indigenous practices, native knowledge, and sacred ceremonies for monetary or other self-gratifying gains.

Equally important, you should not facilitate traditional healing practices with native or non-native individuals unless you are an authentic native healer. From time to time, non-native providers have become so enthralled with native culture that they begin to incorporate their interpretation of a traditional healing practice with clients, implying that it is a native practice. Offering this practice to clients misrepresents and exploits native cultures and crosses many ethical boundaries, beginning with the failure to practice within your area of competence.

American Indian and Alaska Native Healing Practices

The specific practices, rituals, and ceremonies involved in traditional native healing vary considerably among tribes, and clients may feel uncomfortable with or feel that they will gain no benefit from practices associated with other tribes. Some American Indians and Alaska Natives may not feel comfortable with ceremonies that have overtly “supernatural” elements (Hartmann & Gone, 2012). Religious preferences may also affect whether a client finds traditional healing practices acceptable; for example, an American Indian with a strong Christian identity may seek healing from his or her church and feel strongly about not wanting to participate in ceremonies that come from traditional spiritual practices.

Many American Indians and Alaska Natives, especially those in urban settings, may be interested in traditional healing but not know much about it. These clients may want education about traditional healing practices before committing to them. Such education should be provided by individuals experienced in these healing traditions—either healers themselves or community elders with strong ties to their traditional cultures.

Some traditional healing practices are common to more than one tribe, including:

Offering tobacco with one's prayers, often done in a group.

Burning herbs or smudging for purification, which can be done alone or in a group.

Participating in a talking circle, where an object is passed from one person to the next, and each participant is listened to, allowing everyone to express feelings and thoughts.

Giving herbal medicines either to an individual or to members of a group as part of rituals or for their medicinal properties.

Performing a sweat lodge or spirit lodge, in which participants sit in an enclosed structure around a pit of hot rocks—a communal experience of purification, prayer, and healing that has been found to improve emotional and physical well-being.

Performing tribal dances—community events, some of which may be physically strenuous.

Chanting and singing in groups, which require intense participation and can go on for days.

Creating personal medicine bags that hold specific meaning for the owner.

Engaging in other traditional ways, such as going to a winter fish camp, carving, tanning hides, and the like.

In the North section, you will read more about how to integrate American Indian and Alaska Native spiritual and healing practices into a behavioral health program.

American Indian and Alaska Native Perspectives on Behavioral Health Problems

American Indian and Alaska Native clients' views of behavioral health interventions will likely contain elements of both traditional and mainstream treatment services and possibly from Christian healing traditions. Native people often use both types of treatment services. Nonetheless, as a provider, you need to remember that traditional healing practices do not separate mental disorders from physical and spiritual ones. They do, however, recognize problems that mainstream health care identifies as mental and substance use disorders, even if they are only symptomatic of other underlying problems. Traditional healers may look at someone who would be diagnosed with depression and view the same symptoms as problems stemming from breaking a taboo or from unbalanced relations with family or community. Whatever the cause, the symptoms would still call for treatment to restore balance and harmony.

For many behavioral health issues (e.g., substance abuse, suicidality), the underlying cause may be the loss of connection to traditional native culture, historical trauma, and conflict between native and mainstream culture. For example, Native American recovery movements have traditionally viewed alcohol as an instrument in the European subjugation of native peoples. This is one reason that many American Indians and Alaska Natives talk about their culture as a form of healing or prevention, particularly in relation to mental and substance use disorders. Participation in traditional cultural activities (e.g., potlatches, pow wows, crafts, singing, dancing) is a component of many behavioral health programs that provide services primarily to American Indian and Alaska Native clients. However, if clients in early recovery have used alcohol or drugs during community activities in the past, they may need to limit participation or acquire support before and during community activities as a relapse prevention step.

METHAMPHETAMINE IN INDIAN COUNTRY

Methamphetamine has disproportionately devastated native tribal communities. Mexican drug cartels have been deliberately targeting rural reservations for the sale of meth and as distribution hubs. Native Americans now experience the highest meth usage rates of any ethnic group in the United States.

“Some of the reasons drug cartels have targeted Native communities are the complex nature of criminal jurisdiction on Indian reservations, and because Tribal governmental police forces have been historically under funded and understaffed. However, given this new challenge, Tribal leaders have been at the forefront of new and creative solutions and approaches that many other communities may find helpful in their struggles” (National Congress of American Indians, 2006, p. 1).

For more information on substance use patterns and their effects on behavioral health, see Part 3, the online literature review, and the American Indian/Alaska Native Behavioral Health Briefing Book (IHS, 2011).

Mental and Substance Use Disorders Among American Indians and Alaska Natives

You are already aware that American Indians and Alaska Natives are at increased risk for certain behavioral health conditions (e.g., substance use disorders, anxiety disorders) and related problems (e.g., suicidality). The sections that follow will help you understand how such disorders affect American Indians and Alaska Natives and the reasons behind this increased risk. For a detailed review, please refer to the TIP's online literature review.

Alcohol and other substance use disorders

American Indians and Alaska Natives generally start using alcohol and other substances at a younger age than do youth from other major racial/ethnic groups. Early substances use is linked with greater risk for substance use disorders. Poverty and unemployment, common problems for Native Americans, are themselves risk factors for alcohol and other substance use disorders, as are the disruption of families, trauma exposure, historical trauma, and continuing discrimination.

The primary substance of abuse for American Indians and Alaska Natives, as it is for Americans in general, is alcohol. Although many Native Americans do not drink at all, binge drinking and alcohol use disorders occur at high rates relative to other populations. Binge drinking among American Indians and Alaska Natives largely reflects the drinking patterns to which they were first exposed when alcohol was introduced to their cultures through the drinking patterns of White American frontiersmen, fur traders, and others. Other factors also influence binge drinking, such as the difficulty of consistently getting alcohol on dry reservations or in remote native villages, the perceived or established social norms surrounding the use of or abstinence from alcohol at local community events, and unemployment and poverty (which may mean for some that alcohol can only be purchased intermittently).

IS BINGE DRINKING DANGEROUS?

Binge drinking, or consuming large amounts of alcohol in a short period, causes serious health risks despite the recovery periods between binges. The body metabolizes alcohol at a fairly steady rate. When larger amounts of alcohol are consumed, the body is not able to keep up with the consumption. Higher blood alcohol concentrations occur, and the body and its organs are exposed to the higher concentrations for longer periods. This leads to cumulative and devastating effects on the body. Binge drinking is associated with higher death rates, injuries, heart attacks and other cardiac problems, liver damage, poor control of diabetes, and cancer. Additional factors, such as gender and age, influence the body's ability to metabolize alcohol.

The second most common substance of abuse for Native Americans is marijuana, and American Indians and Alaska Natives are more likely to develop cannabis use disorder than are members of many other racial groups. Both methamphetamine and prescription opioid abuse are growing problems for American Indians and Alaska Natives and are of major concern in a number of native communities. Geographic factors partly affect patterns of substance use (e.g., Native Americans are more likely to live in states where methamphetamine abuse is more common), as do the same risk factors that affect alcohol abuse.

Mental disorders

Among American Indians and Alaska Natives, the most significant mental health concerns today are traumatic stress, depression, anxiety, and bipolar disorders (see Part 3's literature review for more information). Research suggests that American Indians and Alaska Natives are more likely than the general population to have psychological distress that interferes with daily functioning and to have higher suicidality. As with other populations, mental disorders in American Indians and Alaska Natives frequently co-occur with substance misuse and substance use disorders.

Important differences exist among native cultures as to the types of symptoms they most often express or report to providers. For instance, American Indians and Alaska Natives are more likely to report somatic (physical) symptoms related to depression. Keep in mind that physical and psychological symptoms are not typically separated from each other.

Depression is a common diagnosis associated with traumatic stress and is one psychological consequence of it. American Indians and Alaska Natives experience very high rates of trauma with the background of historical trauma. Individual traumas—including suicides in the community, domestic violence, physical and sexual assaults, and accidents—are the most common traumas contributing to the development of traumatic stress disorders. The effects of historical trauma and other traumas can negatively affect behavioral health and may increase the risk of developing substance use, mood, and anxiety disorders.

Preferences and Barriers Regarding Behavioral Health Services

Preferences

Many providers believe the myth that American Indians and Alaska Natives do not seek treatment for mental and substance use disorders. In stark contrast to this stereotype, native people actively seek help from traditional healing, mainstream treatment, and mutual-help groups, or a combination of these interventions. American Indians and Alaska Natives who live in native communities and are more traditional prefer services provided in the community to those provided off the reservation or outside the community and traditional healers over mainstream behavioral health service providers. However, even on reservations, clients will use both mainstream and traditional healing. Although some individuals may prefer American Indian and Alaska Native providers, cultural competence and interpersonal qualities play a significant role when it comes to provider preference.

Some individuals may prefer to travel a considerable distance to seek services off the reservation if they are concerned about maintaining their anonymity in their local community. For instance, it is highly probable that clients will know people working at the treatment program if they seek services within their community. Your clients may also be reluctant to attend the program because it is located somewhere where it is difficult to remain anonymous when entering the building or parking their cars.

American Indians and Alaska Natives use behavioral health services at a rate second only to White Americans and may be even more likely to use substance abuse services specifically. They are more likely to believe that people with mental disorders can get better without professional help and less likely to believe that therapy can teach people new ways of coping with problems.

It may be easy to mislabel clients' reluctance to use mental health services as treatment resistance or the result of prejudice against people with mental illness. However, reluctance may result from well-grounded, historically based mistrust in outside institutions. This is a response to events such as the history of boarding school placement and unwarranted removal of native children to non-native foster and adoptive homes.

Screening and assessment of psychotic disorders are difficult in some Native American cultures that consider seeing visions a positive event not necessarily indicative of psychosis.

Barriers to treatment services

American Indians and Alaska Natives face many barriers to accessible health care, including behavioral health services. These obstacles contribute significantly to the development of health disparities among native people. There are different levels of barriers regarding the use of behavioral health services (e.g., sociocultural, systemic, individual), and these obstacles need to be anticipated. Addressing systemic barriers, such as insufficient government funding, may be too great a challenge for an individual provider, but some obstacles are within your control. You may be able to address these obstacles directly or find creative ways around them; the first step is taking the time to understand the most common barriers. The following list highlights common barriers to treatment:

Physical distance from service providers

Concerns about maintaining anonymity in smaller communities

Shame and prejudice associated with mental health services

Lack of child care and transportation

Perception that treatment contradicts cultural values of noninterference and self-reliance

Limited number of American Indian and Alaska Native providers

Lack of culturally competent providers who fully understand things such as emotional expressions, the role of historical trauma in presenting symptoms, and the effects of the cumulative stress of violence and discrimination

Failure to consistently conduct individual assessments on cultural identification and traditional healing practice preferences

Limited funding or treatment options of tribal or community services

Failure to establish cultural brokers, including tribal leaders or native mentors, to help in arranging traditional healing practices from authentic providers

Inability to provide services in native languages

Mistrust of government-funded social services

The North section that follows presents more information on how to adapt your program to make it more effective for American Indian and Alaska Native clients, including how to integrate traditional healing and cultural activities and how to modify standard behavioral health interventions to integrate native culture.

Arriving in the North: The Direction of Culturally Specific and Responsive Skills and Practices

How can your knowledge about American Indian and Alaska Native cultures help you provide treatment that is more effective for your clients? In the North quadrant, you will find answers to that question. The North will give you information about how to modify your behavioral health services to best meet the needs of American Indian and Alaska Native clients.

Native American clients will likely feel more comfortable in treatment and have better outcomes if they find that you understand their culture and respect it and them. Prevention programs are more effective for American Indians and Alaska Natives if you spend time learning about their community and culture.

Not all American Indian and Alaska Native clients identify with or wish to connect with their traditional cultures, but culturally responsive services offer all clients a chance to explore the impact of culture (including historical and generational traumas), acculturation, discrimination, and bias and how these relate to their mental and substance use disorders. They also assist interested clients in recognizing cultural strengths that can support recovery. Adding American Indian and Alaska Native cultural practices to a program can improve outcomes for all clients.

Cultural competence is important throughout the continuum of outreach, prevention, treatment, and continuing care. Part 2 of this TIP discusses considerations for cultural responsiveness in outreach, operational issues, and treatment environments, as does TIP 59 (SAMHSA, 2014a).

Culturally Responsive Relationships: Provider Guidelines and Considerations

As your understanding of native cultures increases, you will see how your behavior in treatment settings can positively or negatively affect your relationships with American Indian and Alaska Native clients, whom mainstream behavioral health services often fail. Providers sometimes label American Indian and Alaska Native clients as unresponsive or resistant to treatment because they do not recognize their clients' preferences or needs and how best to positively address those needs and concerns that initially brought them to treatment. This failure may occur at a programmatic level, but it can also result from interactions in which clients perceive providers as paternalistic, impatient, disrespectful, or ill-informed about their cultures.

To avoid some potential problems in counseling American Indian and Alaska Native clients, remember the following general guidelines for providing care, fostering communication, and building relationships. These guidelines may improve services for many American Indian and Alaska Native clients, but consider each in light of what you know about your individual client.

Knowing yourself

Be who you are. American Indians and Alaska Natives prefer providers who are authentic—who can simply be themselves. Respect your own cultural heritage and be willing to talk about it from the outset. Do not try to be “Native American” or to act in preconceived ways that fit your views of how American Indians and Alaska Natives behave. Doing so disrespects clients' culture. However, you should adjust your treatment approach to be culturally responsive.

Use your own experience. American Indian and Alaska Native clients may not respond well if you simply tell them what they should do, but they will respond positively to you if you share your own experiences of how you have coped with problems or of how others in your practice have dealt with their presenting issues. Remember that many native people often see those giving them advice as meddlers. This perception can be simply stated, “If I respect you, I will not interfere in your life.” Native clients are more likely to be initially suspicious of services or individual providers until a relationship has formed—so be wary of giving advice too quickly. If you offer suggestions, make sure you yourself can follow them. Remember, “Walk the walk; do not just talk the talk.” For example, if you emphasize the value of community, then it is important to periodically attend local community cultural events.

Health problems are associated with higher rates of depression. American Indians and Alaska Natives often report a triad of depression, diabetes, and alcohol abuse. Cardiovascular disease has joined this equation and is a leading cause of death in native people in recent years.

Supporting communication

Listen and respect silence. The most important thing you can do is listen. Many American Indian and Alaska Native people are slow to speak. There are good reasons for this; they believe that words are important and must be chosen, and your clients may need to think carefully about what they are going to say before they say it. In some native cultures, being quiet is a way of showing respect. If English is a second language, clients may pause between sentences to allow themselves to translate their thoughts before speaking. Make sure to give people time to formulate an answer before you move on. Accept that there will be times of silence and that this silence is not “unproductive.” Be patient and avoid jumping in to finish your clients' sentences.

Adjust your eye contact. In some American Indian and Alaska Native cultures, it is disrespectful to hold eye contact. You will have to judge what seems appropriate for the client you are treating. If your client does not want to make eye contact, then do not, and do not assume because he or she looks away that he or she is not interested or being dishonest. Your client may be trying not to be disrespectful to you, or he or she may be thinking about how to respond.

Observe nonverbal communication. As you listen and observe, you may feel that you miss important parts of the conversation. Some communication is unspoken, implied, or embedded in the conversation or story. Nonverbal communication and the space between verbal exchanges are important. The best way to learn communication styles is to observe clients and others in the community and to ask questions about nonverbal communication, including nonverbal cues.

“A man's life proceeds from his name, in the way that a river proceeds from its source.”

N. Scott Momaday (1976, p. 49), Kiowa, quoting his great-grandfather, Pohd-lohk

Determine and value linguistic preferences and abilities. Language is important. Many anthropologists believe language is culture: once language is lost, the knowledge that accompanies that language is lost as well. This is particularly devastating for native communities, which have relied on the oral tradition, particularly for storytelling. Many American Indian and Alaska Native communities are working to save their languages before the few elders who are fluent are gone.

For most American Indians and Alaska Natives, English is their primary language, but about 15 percent speak a native language in their home, and about 13 percent speak another language other than English, usually Spanish (Siebens & Julian, 2011). A number of those individuals speak English as a second language. You should ask American Indian and Alaska Native clients whether they are comfortable receiving services in English, and if not, connect them to services in their own language or find a trained translator to assist in providing services. Some native languages have fairly few speakers, so a translator may not be available in your area, but providing services with a translator who is teleconferenced into treatment sessions is one option that you may consider (TIP 60, Using Technology-Based Therapeutic Tools in Behavioral Health Services [SAMHSA, 2015], has more information on this option).

Native American Indian communication style can be comparable to the spokes on a wheel, and, out of respect for the listener, the main point may be left implicit.

Source: LaFromboise, 1995.

Use hopeful language and avoid labeling. Mainstream behavioral health models often emphasize diagnosing and treating the “disorder.” However, focusing on naming the disorder is likely to be counterproductive with American Indian and Alaska Native clients. In native cultures, names and naming traditions are extremely important. Naming a person identifies those traits a person is expected to live up to. Thus, labeling a client as having a specific disorder can be a form of self-fulfilling prophecy. Naming a disorder may also be shaming to American Indian and Alaska Native clients.

The same concerns apply to discussing prognosis. Some clients may believe that stating something that could happen in the future will cause the event to occur. You may find this belief particularly challenging if you tend to focus on the consequences of substance abuse. Yet American Indian and Alaska Native community members may not readily seek treatment with you if prognosis is a common part of your approach. They may believe that the future is unknowable, save to the Creator. Before discussing consequences of behaviors or disorders, seek the counsel of someone knowledgeable about your clients' culture and ask clients about their beliefs and preferences.

Frame things in more hopeful terms and use a strengths-based perspective whenever possible. Calling an American Indian or Alaska Native “a person in recovery” rather than “a person with an alcohol use disorder” will likely improve the client's reaction and possibly the prognosis.

Remaining flexible and embracing new opportunities

Be flexible with your time. American Indians and Alaska Natives sometimes speak of “Indian time,” which reflects an attitude that things will get done in their own time or in the “right” time and not according to predetermined schedules. If possible, try to accommodate this, and be prepared for clients who may want to contact you after your office hours. Have an open-door policy and hold office hours for drop-in visits. Do not take it personally when clients arrive late; work with them to find solutions that meet both your needs.

“As a counselor working at the university's health services serving Native American students, I found that setting aside recurring time slots during the week for drop-ins increased participation in other services, including prevention activities. This open-door approach created a welcoming atmosphere.”

—Anonymous

Expect more family involvement. For many American Indians and Alaska Natives, family is central. Family can be an excellent motivator for help-seeking and a support to recovery. If your client is connected with family, he or she may want family members to participate. However, as with all families, some family members may be a source of conflict or unsupportive. If your client is estranged from family, this is an important issue.

It is likely that your American Indian and Alaska Native clients' families will want to be involved to a greater extent than families from other racial and ethnic backgrounds. The definition of “family” for American Indian and Alaska Native clients will likely include extended relations, such as second cousins, family friends, and other unrelated community or village members. It is important to avoid using your own definition of family in determining who should participate in family sessions. Likewise, family hierarchies, structure, traditions, roles, and rules may vary from tribe to tribe. Therefore, it will be crucial to learn about families and family systems in the context of tribal affiliation, acculturation level, and individual and community historical events.

Anticipate laughter. Most American Indians and Alaska Natives have an incredible sense of humor. This love for laughter and the use of humor span many generations. Humor is often a means of addressing and surviving many difficult and painful situations. It can also help address a specific problematic behavior without showing disrespect to an individual or family. The role of humor and its intricacies within native cultures cannot be explained in one or two paragraphs. It is a central aspect of native life, yet this attribute often goes unnoticed by non-natives.

AMERICAN INDIAN AND ALASKA NATIVE HUMOR: ITS ROLE IN COMMUNICATION AND HEALING

“One of the best ways to understand a people is to know what makes them laugh. Laughter encompasses the limits of the soul. In humor, life is redefined and accepted. Irony and satire provide much keener insights into a group's collective psyche and values than do years of research.

“It has always been a great disappointment to Indian people that the humorous side of Indian life has not been mentioned by professed experts on Indian Affairs. Rather the image of the granite-faced grunting redskin has been perpetuated by American mythology.

“The Indian people are exactly opposite of the popular stereotype. I sometimes wonder how anything is accomplished by Indians because of the apparent overemphasis on humor within the Indian world. Indians have found a humorous side of nearly every problem, and the experiences of life have generally been so well defined through jokes and stories that they have become a thing in themselves.

“For centuries before the white invasion, teasing was a method of controlling social situations by Indian people. Rather than embarrass members of the tribe publicly, people used to tease individuals they considered out of step with the consensus of tribal opinion. In this way, egos were preserved and disputes within the tribe of a personal nature were held to a minimum.

“Gradually people learned to anticipate teasing and began to tease themselves as a means of showing humility and at the same time advocating a course of action they deeply believed in. Men would depreciate their feats to show they were not trying to run roughshod over tribal desires. This method of behavior served to highlight their true virtues and gain them a place of influence in tribal policymaking circles.

“Humor has come to occupy such a prominent place in national Indian Affairs that any kind of movement is impossible without it. Tribes are … brought together by sharing humor of the past.”

Source: Deloria, 1988, pp. 146–147.

As a provider, you need to know that humor may significantly help your client to be more resilient. Humor can promote healing. Equally important, humor can have implied or hidden meanings. Do not readily assume that humor is a defense to distract from underlying issues. Think about the context of the humor. It may express straightforward humor, indirectly emphasize the importance of something, distract from painful experiences, or signal that trust is evolving in the relationship.

Give things time. You may misjudge the strength of relationships with American Indian and Alaska Native clients because you think sufficient time has passed for these relationships to solidify. Therapeutic relationships with American Indian or Alaska Native clients may take more time to develop than relationships with other clients. Native clients may be suspicious because of prior provider experiences that did not go well or because they see you or your program as representations of a government that has, more often than not, hurt rather than helped American Indians and Alaska Natives. The time it takes for American Indian and Alaska Native clients to develop a relationship with you may also indicate that they are taking the relationship seriously and evaluating it carefully. Thus, it is essential that you take sufficient time to show clients that the relationship is important to you as well and that you value each client as a person, rather than as a “task” that you are trying to complete.

Plan to provide practical assistance as well as therapy. From a holistic perspective of health and healing (i.e., perceiving everything as connected), it is natural for clients to expect broader discussions and to seek help that falls outside a typical behavioral health focus. This may include discussing concerns about or seeking suggestions from others in the community. Like many clients who seek behavioral health services, American Indians and Alaska Natives have multiple needs. Treatment planning should include a “case management” approach that helps address housing, transportation, education, vocational training, unemployment, legal assistance, physical health care, child care, relationship and community concerns, and domestic safety. A more expansive view of treatment will strengthen your therapeutic relationship and help you give native clients the support necessary for long-term recovery.

Be open to new ways of conducting treatment. As you work with American Indian and Alaska Native clients and with other providers who are experienced in providing services for Native Americans, you will likely hear of different techniques and activities that can enhance services for your American Indian and Alaska Native clients. You may need to consider using different interventions or altering interventions in some way. For example, if talk therapy is difficult for your clients, you might consider incorporating more experiential exercises in the session, such as walking meditation, using artwork to tell a story or display a current struggle, visualizations, or sculpting (see the “Sculpting: An Experiential Approach to Treatment” box).

Mainstream approaches may not be an effective avenue, and they may not be the first step in treatment. It is important for some native people to seek consultation with a traditional healer prior to coming to a counseling program. For others, a referral to a culturally oriented program may be more appropriate (e.g., Alaska Native spirit and cultural camps). Adjustments will need to be made on an individual basis to provide the most appropriate treatment, but it will be helpful if you can present clients with options.

SPIRIT AND CULTURAL CAMPS

“For those working with individuals who struggle with the effects of alcohol and other substance abuse in their lives, it has become increasingly evident that the pathway to healing is substantially stronger for those who have been raised with traditional Alaskan values [when they] reunite with those values” (First Alaskan Institute, n.d., p. 9). In the past decade, communities have developed several treatment program alternatives using a camp setting model to provide spiritual and cultural guidance (e.g., the Tanana Chiefs Conference Old Minto Family Recovery Camp, an Athabascan alternative to substance abuse treatment).

The camps offer a path to prevention for children and adults and a way to recovery for families. Many camps are seasonal and provide opportunities to connect, experience, and practice traditional ways (e.g., subsistence practices, language, dance, history). Some camps are specifically organized to address substance use disorders and recovery through an integrated cultural approach using community, group, and individual modalities.

SCULPTING: AN EXPERIENTIAL APPROACH TO TREATMENT

Sculpting is a tool for making an external picture of an internal process such as an experience, a perspective, feeling, or presenting concern. It includes the use of postures, positions, gestures, spacing, and objects to demonstrate a presenting issue or theme. For example, imagine a family photograph. Now picture the client as the photographer who asks other participants to stand in a certain position in relationship to one another. In sculpting, the client is the photographer, and you are the assistant who guides the process.

The photographer (client) repositions other people in the room to demonstrate current concerns. In a group setting, you might have the person create a picture using other group members to demonstrate the potential barriers to abstinence. The client would discuss and name each barrier, then each group member would represent one or two barriers, and the client would position them according to importance. Or you, the provider, might become the photographer so that you can demonstrate a concept or pattern for the client. For example, you might help the client name personal strengths that he or she has demonstrated throughout his or her life, followed by setting up a picture of these strengths, either using group members or a drawing (if it is an individual session). In doing so, the individual receives a powerful picture: it is knowledge that the client will not likely forget, because it goes beyond words. It is a powerful physical, emotional, and visual experience.

Recognize and support the significant role of prevention in American Indian and Alaska Native communities. As a provider, you need to understand that native communities believe that cultural knowledge and practice are the pathway to prevention and healing. Many American Indians and Alaska Natives view mental and substance use disorders through a historical lens whereby such disorders are illnesses of infliction characterized by historical losses, deculturation, and racism. Individual behavioral health conditions are seen as symptomatic of the aftereffects of this history in the community. Honoring children and young people is a common tenet of American Indian and Alaska Native cultures. Without culture and the young, there is no future. Therefore, considerable efforts are underway to maintain, introduce, and teach cultural traditions and other cultural knowledge as prevention activities. Likewise, communities are using community readiness assessment and prevention strategies to help address specific problems represented within the community. As a provider, it is important to promote, support, house, and help facilitate the development of these prevention activities in native communities.

Making introductions as a provider: First meeting

Remember American Indian and Alaska Native etiquette for introducing yourself. Be sure not only to give your name and job title, but also to explain briefly something about yourself, what you are doing, and why. It may help if you can use some examples from your own experience. It is often far more important to talk about who you are than what you have done. For example, talk about things such as your family (past or present), your birthplace, and where you grew up. You should also introduce your program and what it does, as not all clients will have prior experience with behavioral health services or understand how they work. American Indians and Alaska Natives generally want to know who you are before deciding if they should trust you. Take your cue from clients when it comes to offering a handshake and expect that it may be very light rather than hearty; this is a sign of politeness and respect in some tribes. Keep your eye contact brief at first until you observe the habits of your clients. This, too, could be a sign of respect. Listen carefully to how your clients introduce themselves. Get comfortable with your own silence rather than allowing your potential anxiety about silence in a conversation to push you to talk too much or ask too many questions.

Explain confidentiality. All clients may have concerns that information about themselves and what they say in treatment might be shared with others, but this is an especially strong concern in smaller, rural communities such as those that exist on many reservations. You should tell new clients what information will be shared and with whom. As mentioned earlier, clients may have strong concerns about being seen entering a treatment facility or parking their car outside. One solution is arranging alternative transportation, if available. Another major concern about confidentiality is that clients may know someone who works at the facility. In a small community, it is common to have relatives or other people clients know working in the program they are attending. This can be a significant barrier. Clients may not believe in the promises and policies of confidentiality. After gaining consent, connecting clients with other community members who are in recovery may help decrease these concerns. Sometimes, these concerns will only be alleviated by referring clients to another facility.

American Indians and Alaska Natives have historical cause to wonder whether behavioral health service providers will recognize them for who they are, respect them, and assist them in walking their life paths. History has taught native peoples that it is dangerous to trust outsiders. Their lives—the lives of their parents and grandparents—have been taken or forever altered by outsiders.

Choosing Directions: Intake, Assessment, and Treatment Planning

This section is not a primer on how to complete intakes or assessments or how to develop treatment plans; it is expected that you know how to conduct these tasks. Instead, the suggestions presented below highlight several key ingredients and considerations when planning services with your American Indian and Alaska Native clients.

Obtain clients' perspective first. Ask how your clients see the current situation, what led up to the current concerns and the decision to enter treatment, what caused the problems, and what thoughts they have about how to return to a more balanced state. Ask what clients have already heard about the kinds of concerns or problems they are having and what steps or paths they have already taken to heal or gain relief. How do they see the problem? Ask how it affects different aspects of their lives: spiritual, relational, emotional, physical, and mental. How does what other people say about the problem affect your clients? Ask them what they may need to do to heal and what successful healing would look like for them. Also listen for clients' motivation for recovery. Common motivations for addressing mental illness and substance use disorders include the need to be a responsible parent or involved family member, the importance of religious and spiritual practices, criminal justice involvement, and the need to support a healthy community.

Your clients may view intakes and assessments as unnecessary. Some American Indians and Alaska Natives are accustomed to traditional healers who know what their problems are without taking a history. Engage the client before paperwork.

Explore and assess cultural identity. It is vital to spend time understanding the way individuals frame their own cultural heritage throughout their lifetime—from the past to the present. As you spend time with your clients, listen for the importance and influence of native culture. Some clients may have little connection or identification with American Indian and Alaska Native culture; other clients may have strong ties to native culture and primarily relate to the world in traditional ways. Most clients will identify with a particular native culture or cultures, but some will have a more pan-Indian identity. Many who grew up in traditional and mainstream culture will have adopted a bicultural perspective, maintaining their identity as American Indian or Alaska Native and operating in both the traditional and the mainstream cultures. Cultural identity does not need to be assessed using an inflexible continuum that perceives the process of becoming acculturated to a new culture as lessening one's identification with one's original culture. American Indians and Alaska Natives have clearly demonstrated fortitude, resourcefulness, and an ability to negotiate both cultures at the same time. There are a few instruments available to assess cultural identity for American Indians and Alaska Natives, such as the Native American Acculturation Scale (Garrett & Pichette, 2000).

QUESTIONS TO HELP YOU ASSESS CULTURAL IDENTITY

Learning how your clients identify with their culture will help guide the healing process and influence the selection of treatment approaches. Asking open-ended questions will help you learn more about your clients' treatment preferences and needs as well as their identification as American Indians and Alaska Natives. For illustrations on how to ask questions, use the Native American Motivational Interviewing Manual (Venner, Feldstein, & Tafoya, 2006). It suggests questions such as, “For many native people, cultural identity is important, and people have all different levels of comfort and belonging with one or more cultures. What is important for me to know about your cultural identity as we begin to work together?” (p. 53).

Below are some sample questions. As a precautionary note, remember not to move quickly from one question to the next. Take your time. In addition, remember that it is inappropriate and disrespectful to ask for detailed information about ceremonies.

How do you self-identify?

Who raised you?

Where were you raised?

Who is in your family? Who is helping to raise your children?

How have you been exposed to the culture of your tribe? Stories? Ceremonies? Community events?

What languages do you speak? Which do you prefer?

How would you describe your spiritual beliefs? How do you practice your spirituality?

What is your experience with traditional healing practices?

How important is it to you to work with a healer or medicine person in addition to your treatment here?

Do you have a traditional healer or advisor who is currently working with you?

Assess trauma, including historical trauma. American Indians and Alaska Natives experience high rates of trauma and traumatic stress responses, such as PTSD. They disproportionately experience many kinds of trauma, including types that may be particularly difficult for clients to discuss (e.g., childhood abuse, sexual abuse). Still, it is important that you evaluate the trauma experiences of your American Indian and Alaska Native clients, as such experiences can affect behavioral health in many ways. TIP 57 (SAMHSA, 2014b) discusses how trauma can affect behavioral health and how to assess trauma and its effects.

As you read in the East section, historical trauma is an important concept for understanding American Indians' and Alaska Natives' behavioral health, and many clinicians who work with this population identify the assessment of historical trauma response as a key element in behavioral health services for American Indians and Alaska Natives. The “Symptoms of Historical Trauma Response” box presents possible symptoms of response to historical trauma.

SYMPTOMS OF HISTORICAL TRAUMA RESPONSE

Survivor's guilt

Depression

Psychic numbing

Emotional fixation on trauma

Low self-esteem

Victim identity

Anger

Self-destructive behavior

Substance misuse

Hypervigilance

Compensatory fantasies

Preoccupation with death

Death identity (e.g., fantasies of reunification with the deceased)

Loyalty to ancestral suffering and the deceased

Internalization of ancestral suffering

Internalized oppression

Source: Brave Heart, 2005.

Identify treatment goals that are important to your clients. As with all your clients, you will need to help your American Indian and Alaska Native clients identify treatment goals that are appropriate and meaningful for them. If your program primarily serves American Indians and Alaska Natives, then your program and your colleagues will help guide you in developing effective treatment plans. Experience working with American Indian and Alaska Native clients will improve your ability to develop culturally responsive plans.

Your planning should reflect information you have gathered from talking to and spending time with your clients. As you learn more about your clients' lives, their degree of cultural affiliation, their religious or spiritual beliefs, and the stories of family members, you will need to adjust your plans to make the best use of clients' strengths, supports, values, and cultural identity.

Keep in mind that your client's values and beliefs may be different from yours. For example, you may hear less about goals of personal achievement and success and more about goals of being a contributing family and community member and upholding the pride and traditions of the native culture. Spend time discussing with your client what he or she might need to do to obtain balance in life and heal from present difficulties.

The following are some common themes that may be identified in treatment planning:

Connect or reconnect with traditional ways of life and practices.

Identify cultural strengths and how to use these strengths when distressed or in maintaining recovery from substance abuse.

Gain greater understanding of the role of personal and historical trauma in presenting symptoms and substance misuse.

Find opportunities to participate in community events that support recovery.

Reflect on how alcohol or other substances have interfered with cultural identity or practices and affected relationships with others.

Consider how introduction, sale, and use of alcohol and drugs contributed to oppression.

Identify elders, family members, and other community members who will support recovery.

Explore how spirituality might help with present difficulties.

Incorporate options for cultural activities in treatment planning. Connecting or reconnecting American Indian and Alaska Native clients to cultural practices can improve their behavioral health and quality of life. If clients so desire, treatment plans should accommodate cultural and spiritual activities that can support recovery from mental and substance use disorders. Seek help from members of clients' tribes to determine the appropriateness of an activity, because a community event may involve alcohol, thus increasing your clients' exposure to alcohol and other substances that may compromise recovery.

The specific activities involved will vary according to the client's preferences and the native culture to which he or she belongs. Some activities (e.g., spirit camps, ceremonies, traditional hunting or fishing) may need to be scheduled independently outside the treatment center, whereas others (e.g., sweat lodges, traditional crafting, smudging or purification, talking circles) may be conducted at the program site and integrated with counseling activities. By providing opportunities to meet community elders, traditional healers, and native peer support and recovery coaches, your client will have a clearer image of what healing pathways he or she needs to choose. Providing these activities can help your client connect to traditional practices that may more effectively communicate important lessons and address his or her presenting problems.

Provide alternative methods for receiving services, if needed. If you work in a program that already provides telecounseling, uses the Internet for videoconferencing, or holds recovery meetings by conference call, you know these are effective ways of providing behavioral health services. (See TIP 60 [SAMHSA, 2015] for more information on using these technologies.) Many Native Americans, particularly in Alaska, live in remote areas and may be unable to access services at an agency or program. In such cases, phone or computer technology may be the best way for clients to connect with behavioral health services. Another alternative method is the use of mobile treatment programs for integrated behavioral health services that provide more services than the more common mobile crisis units (see Jiwa, Kelly, & Pierre-Hansen, 2008). Although the approach is still in its infancy, integrated mobile units can provide a one-stop center to address health from a holistic perspective, including substance abuse, mental illness, and other health issues. Mobile units are a viable alternative for native communities that face barriers to accessibility.

After participating in specific ceremonies, the client may need to observe practices as outlined by the healer, such as avoiding specific types of food. You can talk with the traditional healer and the client to understand any restrictions or practices that the client will need to follow.

Engage American Indian and Alaska Native healers in treatment. There are many paths to recovery, and traditional healing practices can work well alongside the treatment you offer. Traditional healing ceremonies can be powerful experiences that help heal a variety of behavioral health issues. Traditional healers can also be valuable allies, helping you adapt your treatment to be more effective. When your client is working with a traditional healer, ask if he or she would like to invite the healer to help plan the treatment. Traditional healers may be able to help connect your client to American Indian and Alaska Native recovery communities and can continue to support his or her recovery and promote positive change after your client has left the program. Ask him or her to coordinate with you in your work with American Indian and Alaska Native clients.

If your client is not working with a traditional healer, ask if he or she would like to do so. Your client may know of a healer or may need assistance in locating one who is appropriate, as there are different types of traditional healers and traditional healing practices, depending on the tribe and training of the traditional healer. Although you may want to be helpful in contacting a traditional healer, your client may have a specific belief about the type of healer best suited to his or her problems. Therefore, talk with your client first, and determine together how to arrange access to a traditional healer.

There are no organizations to certify native traditional healers, so you will need to talk with clinical supervisors, other providers, elders, tribal organizations, or people in the community to find appropriate ways to integrate authentic traditional healers. Some healers will only work with members of their own tribe, just as some clients will only want to engage in healing practices that are from their own tribe. Some clients will also avoid traditional healers because of religious differences, although their own church (e.g., the Indian Shaker Church, the Pentecostal Church) may have healing practices. Also, some traditional rituals are only meant for men, and healers may exclude women from participating. Some healers may not support all types of behavioral change. If your client population is drawn from several tribes, you will need to develop a network of traditional healers that represent these tribes. Some treatment providers and programs develop a formalized process and agreement with traditional healers ahead of time so that their services are readily available when needed.

Even if an American Indian or Alaska Native client is uninterested in traditional healing, he or she may still wish to have more involvement in traditional native cultural practices. Encourage such participation, as it may have a number of benefits. You can help your client find cultural activities in your area that are appropriate for him or her.

Considering Culturally Adapted Treatment Approaches

The adaptation of mainstream treatment approaches across cultures is still in its infancy, but it is clear that culturally adapting evidence-based interventions congruent with American Indian and Alaska Native worldviews and cultural practices is an effective approach. In choosing an approach with American Indian and Alaska Native clients, it is important to examine the acceptability of the belief system that underlies the modality. For example, therapeutic modalities often focus on the past, present, and future, and, as highlighted earlier, living in the present—the here and now—is a key concept for many native cultures. However, this does not mean that the treatment focus should avoid historical trauma and other trauma (including discrimination), but rather that the discussion should be oriented to present-day paths toward healing and resolutions.

Other considerations in adapting an approach include assessing how the approach matches communication styles, traditional cultural values, cultural taboos and practices, and cultural identity (for review, see Gray & Rose, 2012). For example, rational emotive behavioral therapy is very directive compared with motivational interviewing (MI) and other cognitive–behavioral approaches. Directive, advice-laden, confrontational treatment approaches that deemphasize the therapeutic relationship are contraindicated for American Indian and Alaska Native clients (J. King, Trimble, Morse, & Thomas, 2014). Such approaches can create resistance in people across cultures but are especially culturally insensitive to native people. Of course, this also depends on individuals' cultural identity, level of acculturation, and treatment expectation.

American Indian and Alaska Native clients generally respond well to various treatment modalities, including individual-, group-, family-, and community-based approaches. (For a review of various programs and projects, see Urban Indian Health Institute, 2014.) When considering group therapy, it is important to think about the constellation of the group. Who is in the group? If there are non-natives in the group, how will this affect American Indian and Alaska Native participants? How do you need to conduct the group differently? If all participants are native, does the group contain individuals from diverse tribes? If so, what is the relational history among the specific tribes? Some individuals may initially have a difficult time participating with a member from a particular tribe; other individuals may worry about confidentiality if members from their own tribe or community are in the group.

When it comes to family treatment, it is essential to identify who is family. As with any family process, it will be important to understand and honor the family's history, system, hierarchy, and other dynamics. Culture, historical trauma, and outside influences greatly affect family dynamics. For example, what is the impact of a grandparent's or great-grandparent's boarding school experience on the family system? How does this history influence parenting skills, cultural identity, trust, and traumatic stress?

Community-based interventions are another powerful modality; they address current individual problems through a larger lens. If individual substance use disorders and mental illness are viewed as symptoms of the native community's history of trauma and discrimination, then it is natural to address problems from a broader perspective using culturally based community approaches rather than, or in combination with, individual and family modalities. These approaches are in line with cultural values, and traditional healing practices can easily be an essential ingredient. Community-based interventions are built on a belief in self-determination: that healing and the solutions to behavioral health come from within the community. These interventions will need guidance from native facilitators. They also require a presence and investment in the community, as well as initial permission, acceptance, and participation of tribal leadership and other influential tribal members. Community interventions need to include youth, elders, and other community members.

Native nations have developed many behavioral health programs and interventions to address and find solutions to community problems, such as substance misuse, diabetes, other health issues, suicide, parenting issues, and sexual violence. Talking circles, educational groups, youth gatherings, drum-assisted recovery, outdoor adventure, and cultural heritage days are a few examples of community-based interventions used over the past two decades.

Although culturally adapted EBPs are few, American Indian and Alaska Native practice-based approaches are evolving. Practice-based approaches (knowing what works through experience, clinical judgment, cultural knowledge, and client feedback) are much more culturally responsive and accepted in native communities than EBPs are. Keep in mind that the importance of using EBPs is generated from mainstream ideology. Thus, there is danger in an “outsider” attempting to impose an approach without considering the culture and self-determination of American Indian and Alaska Native communities. Moreover, the research that supports EBPs generally fails to have adequate American Indian and Alaska Native representation.

Culturally adapted treatment practices are generally passed orally from one therapist to another at meetings or other gatherings of providers for native people (Gray & Rose, 2012).

Exhibit 1.1-5 provides information on a selection of culturally adapted treatment practices. Some other prevention and treatment interventions have been evaluated with American Indian and Alaska Native clients, and the number of such interventions continues to grow. For further discussion, see Part 3, the online literature review. Culturally adapted approaches include MI, family systems (i.e., network therapy), community reinforcement, mindfulness approaches, and cognitive–behavioral therapy (CBT). Take into account that this is only a sample and that if an approach is not mentioned below, it does not mean that the approach is a poor choice for American Indian and Alaska Native clients or that it can be provided without modification. When selecting culturally adapted approaches, consider them in light of the specific culture; cultural identity; traditional healing practices; presenting problems; strengths; and needs of the client, family, and community (Trimble, Scharron-del-Rio, & Hill, 2012).

Box Icon

Box

EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches.

Building Supports and Supporting Recovery

Most people across cultures fare better in recovery if they have an adequate support system. This is also true for American Indians and Alaska Natives: community support is often a key ingredient whether you are providing care for someone who lives on a reservation, in another rural area, or in an urban area. Below are some suggestions for how you can improve support systems for your American Indian and Alaska Native clients.

Connect clients to American Indian and Alaska Native recovery supports. Get to know the traditional healers, providers, and programs in your community and the home communities of your clients. By helping your clients connect with traditional healers, family, and community programs, you can help them build a support system that will promote recovery long after they leave your program. You will also need to search out recovery resources in your area that support American Indians and Alaska Natives and learn about their methods. You may need to identify specific supports that are available for tribal members in your area as well as those that might be useful to American Indians and Alaska Natives regardless of tribal affiliation. You can begin by talking with service providers from tribes or urban native programs and your state's behavioral health division. Besides typical recovery supports (such as mutual-help groups), involvement in community activities, when and where appropriate, is an important avenue in recovery promotion for American Indians and Alaska Natives.

Identify appropriate support. Establishing a support system is only effective if it addresses the unique needs of the individual and family. For example, although social support is one of the most important factors in maintaining recovery, the perceived and real probability of encountering social conflict or social pressure is a greater risk factor for relapse of substance use or a reoccurrence of psychological symptoms among American Indians and Alaska Natives than among any other ethnic or racial group. Therefore, it is important not just to ensure support, but also to explore potential conflicts and minimize exposure at least in the early stages of recovery from substance abuse or mental distress. Some individuals have shared that they needed to make major changes in the first year of recovery by staying away from some people and community events to avoid social pressure to use.

“Here the destruction stops.

We will heal ourselves,

We will heal our wounded relationships,

We will heal our children,

We will heal our Nations.

On this day, our future history begins.”

Source: White Bison, 2002, p. C.

Use mutual-help approaches that are culturally appropriate. Mutual-help is often an important part of long-term recovery for people with mental and substance use disorders, including many native people. American Indians and Alaska Natives have a long history of using mutual-help specifically to address alcohol use disorders that continues to this day. Some American Indians and Alaska Natives may have difficulty with the public speaking (and, in particular, public confession) aspect of mutual-help groups, but for those who do participate, mutual-help groups appear to be beneficial.

The 12-Step model is helpful for many American Indians and Alaska Natives in recovery from substance use disorders who typically find its focus on nondenominational spirituality culturally relevant. American Indians and Alaska Natives have made adaptations to this model to make it more culturally appropriate. For example, the Salish Indians (mentioned in “The Importance of Knowing the Specific American Indian and Alaska Native Cultures of Your Clients” box), whose culture had historical precedents for group talk and confession, have made their own adaptations to the model. The Red Road to Wellbriety is an example of melding together the older teachings of native recovery, recovery circles, the code of Handsome Lake, ancestral teachings, and the 12-Step program. “The Red Road is a way of achieving sobriety and healing personal and cultural wounds. The Red Road is a way of breaking the cycle of destruction that so often accompanies historical trauma and oppression” (White Bison, 2002, p. E).

Fostering Community Connections

As an individual provider, you can informally build relationships in American Indian and Alaska Native communities that will help you be more effective and better received by the community, improve how clients and their families and friends perceive you, increase your understanding of your clients' culture, and become aware of the strengths and problems of the communities in which your clients live. If you want to deliver prevention messages, they will likely be better received coming from other community members than from you or your program alone.

Not all areas will have a significant native community, but even away from Indian Country, American Indians and Alaska Natives may have support networks based either on shared tribal identity or, in cases where no tribes are dominant, on a pan-Indian identity. In urban native communities, there are often informal community leaders who are known to and respected by many American Indians and Alaska Natives and to whom they may go for advice. What follows are some suggestions to guide you in developing community relationships within American Indian and Alaska Native communities.

Non-native people often talk to get to know a person. Native Americans may expect that you wait until you know someone before you speak to them in depth or in confidence.

Take your time. Do not move too quickly to establish yourself. Take time listening and learning about how things work in the community. The last thing you want to do when you are new in a community is step on someone's toes or make a mistake that you have to live down later. As an example, a counselor arrives in a small community. Within the first 2 days, the counselor confronts the program director and his supervisor because some staff members are relatives. The director's niece and the supervisor's sister work within the same program. Rather than waiting to build community relationships and to understand the community environment, the counselor runs roughshod over the treatment community and erodes the potential for building relationships inside and outside the center.

Learn about the culture. American Indians and Alaska Natives have very distinct beliefs, languages, traditions, and nations. What is the history and tradition of the people as they tell it? What is their clan system, if they have one? Do they identify more strongly with the mother's or the father's lineage? What are the customs in extended family relationships? Learn as much about the culture as you can through interacting with others, reading native writings, and being an observer and respectful participant in community events. Know proper etiquette in attending community events or if you are invited to ceremonies. When is it appropriate to speak or to be silent? Do not attempt to participate in a dance, drumming, or any other ceremony without a guided invitation. Learn culturally correct terms (e.g., “regalia” instead of “costume”). If you can, find a community member, such as an elder, a provider, or a person in recovery, with whom you can build a close relationship and who can guide you.

Introduce yourself. Try to introduce yourself to all community members whom your work may affect (in a small community, that may be everyone). Tell them what brings you there and what you are there to do and find out how you can best work together without duplicating services. Show respect for how each person lives and for his or her privacy and mind your own business. Remember that you are a guest; they will decide in their own time how they see you based on how you handle yourself. Act graciously and remember that you are there to learn, not to instruct.

Learn from elders. Showing respect for elders is extremely important in American Indian and Alaska Native cultures. They are the bearers of native history, language, knowledge, and ways. Spending time with elders is a good way to learn about the community and earn trust. One way to show respect is by listening without interruption or imposing time limits. This may lead to broader acceptance in the community. Learn the protocol for consulting an elder; you may want to bring a gift.

See and be seen. Learn what kinds of events and gatherings are important to community life and attend them if it is appropriate for you to do so. Educational programs, school and sporting events, and music programs are common community events. If you attend, bring food to share at the event. In some communities, hunting, fishing, gathering berries and roots, tapping trees for maple syrup, and processing these foods are time-honored traditions that are often done as a community, and it may be possible to participate in such activities if you are invited or if you ask. A provider who only stops by to hold office hours risks being seen forever as an outsider who does not understand or even want to understand what life is like in the community.

Respect the intellectual property of native culture. You are not in the position to interpret or comment on cultural values, events, or ceremonies. Equally important, it is not ethical to publish; blog about; or post videos, comments, or pictures related to such cultural property on any social network platform. Confidentiality needs to extend beyond clients' personal information: native culture is the intellectual property of tribal members themselves. Whether or not a tribe asks you to sign a confidentiality agreement regarding their cultural and intellectual property, keeping cultural information private is the correct, moral, and legal thing to do.

Since colonization, American Indians and Alaska Natives have had their culture stolen, destroyed, misused, romanticized, and misrepresented without much thought to the history and existing realities of oppression. As a provider, you need to be sensitive not only to the history of the government's efforts to eradicate native culture, but also to individual actions that have eroded and can further erode native culture. Native culture belongs only to native people. The culture includes, knowledge pertaining to beliefs, language, ceremonies, ways of being, traditions, hunting and gathering sites, medicine, events, sacred items or sites, and artwork.

You may be in a position to provide presentations, reports, or information to other agencies or organizations regarding the use of services, research, demographic data, or case studies of American Indians and Alaska Natives. If so, it will be critical that you first review all releases of information with the appropriate governing body of the particular tribe or people to get approval.

Use your program or facility to provide community services. Many behavioral health programs that serve American Indians and Alaska Natives have found it helpful to integrate a range of services and to host or house cultural and community activities. Some behavioral health programs have integrated services including, but not limited to, HIV testing and prevention, medical services, childcare and family services, housing assistance, job training, life skills training, and parenting classes. Integration of services increases accessibility for clients. Also, the facility needs to invest in the community. A simple approach is to use the facility's space for hosting cultural events, educational programs, and community activities (e.g., a New Year's Eve sobriety pow wow). Doing so increases program visibility and, potentially, community trust. It is far easier to go to a facility that you know than to one that is disconnected from the community.

Be prepared to help communities develop community-wide initiatives. As described in the West section, American Indians and Alaska Natives typically have a holistic view of health that encompasses the individual, the family, and the community, and many native communities have had success with interventions that involve efforts at the community level, such as gathering of Native Americans and community readiness programs (Plested, Jumper-Thurman, & Edwards, 2015). Such interventions may combine legal, prevention, treatment, cultural, and other community-building elements to address health problems, such as substance abuse, HIV, diabetes, sexual violence, suicide, and their effects on the entire community.

Gathering of Native Americans is a 4-day community event that focuses on health and well-being to bring about community healing. This approach values traditions while increasing the community's strengths. This community event addresses topics such as historical and cultural trauma, suicide, and substance abuse, among others.

Treatment programs should not be the main actor in the development of such initiatives. To be effective, community-based interventions need to develop from the will of the community. Usually a few concerned community members will start the ball rolling and may reach out to local providers for assistance. Programs can then provide information, technical assistance, and other support to community members who want to help.

Where Do You Go From Here?

As you have read this chapter, you probably started thinking about how it translates to your day-to-day interactions and responsibilities as a provider. Now that you have some fundamental information, the next chapter will provide more specific information and examples of providing culturally responsive care. You will meet a number of American Indian and Alaska Native clients who are experiencing or have experienced substance abuse or psychological distress. Part 1, Chapter 2, provides stories, examples of client–provider dialogs, and ideas about how to provide care. As you proceed, bear in mind that being a culturally competent provider involves a commitment to learning cultural knowledge, exploring cultural awareness and competence, understanding cultural perspectives of behavioral health, and adopting culturally specific and responsive skills and practices. Not only that, but it also necessitates a willingness to invest in relationships with your clients and the community.

Copyright Notice

This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.

Bookshelf ID: NBK539584

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (2.6M)

Other titles in this collection

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...