American Indians (herein referred to as Indians, Native Americans, or Natives) have a rich and heart-rendering history and continue to contribute to the fabric of American society. The history of Native people is important for mental health professionals and researchers to understand in order to grasp the present implications of history and how they may affect psychological, familial, and social interactions. The following overview of Indian country, past and present, is divided into several sections. A brief history of Native-White relations serves as an introduction to Native peoples. This section is followed by a presentation of demographics and an introduction to the complex definitions that surround being Native. Several myths that are commonly held by non-Indian “others” regarding Native Americans are presented and clarified. This is followed by an overview of health and mental health issues affecting Natives today. The final section presents traditional Native and contemporary approaches to healing, examining the physical, spiritual, and psychological community and group approaches to mental health.
The history of Native peoples can be divided into two major periods: pre-contact and contact. The contact period is generally divided into several subsets, including the periods of Manifest Destiny (1492-1890), Assimilation (1890-1970), and Self-Determination (1970 to the present). Pre-contact was a period of autonomy for tribes that inhabited the Americas. Tribes adapted to the environment they lived in. Varieties of lifestyles included those of hunting and gathering, agrarian lifestyles, and a combination of both, which were determined by the environment and terrain where tribes lived. Complex social and political systems were developed by each tribe. Each group had its own set of attitudes, beliefs, social organizations, men’s and women’s societies, and views of creation, self, and nature. Wicki-ups, teepees (hide and bark), sod housing, and cave dwellings served as homes across the continent. Political practices included input from both men and women in clans or bands and honor societies; this latter respect for women ran contrary to European patriarchy and contributed to the cultural dissonances between colonialists and Natives.
Manifest Destiny, Assimilation, and Self-Determination
With the arrival of Christopher Columbus, a lost sailor who worked for the Spanish, in 1492, Natives were removed from ancestral homes, starved to death, and massacred as a means to secure land and resources. This westward movement was justified under the auspices of Manifest Destiny. This movement was a form of what has come to be known as ethnic cleansing. Native Americans suffered new sicknesses and diseases brought by colonists, illnesses that claimed more lives than combat claimed.
The assimilation era was between 1890 and 1970 and was characterized by efforts to socialize Natives through missionary activities and the practices of boarding schools. Both of these acts of forced assimilation served destructive cultural, social, and psychological influences on Native groups. With the advent of the boarding schools, children often witnessed the loss of tribal life ways. These practices represented the shift from physical genocide to cultural genocide. Common practices of corporal punishment and sexual abuse impeded healthy psychological development and, in many cases, impeded the ability to develop appropriate relationships with others.
This collective past of broken promises, discrimination, and oppressive practices has had resounding effects that have shaped the psychological well-being of many Native peoples today. These effects have been described as historical trauma, the reliving of events, oppressive and violent in nature, retold and experienced in the present through stories shared among families and in social settings. These historical traumas are intertwined with current traumas, the impacts of alcohol and other drug abuse, child abuse and maltreatment, unemployment, poor health care, and death, all of which have profound psychological and social effects.
American Indians comprise many different groups, including over 569 federally and state recognized tribes, each with their own commitment to cultural and spiritual beliefs and practices. There are many tribal groups that are not federally or state recognized by treaties. There are tribes without signed treaties, and, through what is known as the termination period during the 1950s and 1960s, there are tribes who ceased their treaty relationships with the U.S. government. Processing treaties for federal recognition is a complex and lengthy task, as exemplified by the Little Shell Band of Montana, whose struggle has lasted more than 38 years. In deciding to terminate their quest for federal recognition, tribal groups compromise their ability to have a land base and become ineligible for health care or psychological services.
Differences within Native people are evidenced through tribal diversity and rates of intermarriage. According to recent census estimates, there are 4.5 million self-identified American Indians and Alaskan Natives, excluding Hawaiians. Specific tribal populations vary widely in their enrollment. For example, the Dine people (Navajo Tribe) maintain a membership exceeding 298,000 strong. In contrast, the Confederated Salish and Kootenai Tribes of Montana currently have a membership of 7,000, due to blood quantum enrollment criteria (i.e., the degree to which an individual can claim his or her heritage as Native). Many tribes anticipate similar declines in enrollment as a function of blood quantum criteria.
American Indians vary by level of acculturation, often paralleling the acculturation level and degree of collective forced assimilation of their tribes. Individual variations in acculturation level may be related to Native cultural identity development attitudes; length of time away from reservations, including nonparticipation in familial and cultural activities; degree of commitment to learning the culture of one’s tribe(s); and generation level.
Within-group differences can be found across age, language, and social class. American Indians appear to constitute a young cultural group, as a recent estimate indicated that the median age of the population was 29, compared to 36 years for the White population. Furthermore, approximately 1.3 million Native Americans were reported to be under 18, and 336,000 were 65 years or older. However, Native elder population is growing at dramatic rates; specifically, between 1989 and 1999 the Native population aged 65 and older grew by 33%, while the non-Native population of adults over 65 increased by 9%. Additionally, there is linguistic diversity among Native people, such that 28% of all Indians/Natives 5 years of age and older speak a language other than English in their home; of that number, 18% speak English proficiently. Lastly, although there is variability in socio-economic status among Native people, 26% were reported to live at or below the poverty level, according to recent census reports based on a 3-year average.
Many myths abound regarding Native Americans. The following section provides an overview of several of the most commonly held notions about American Indians/Alaskan Natives.
Myth 1: All Natives get a U.S. government check monthly. Natives are eligible for monies such as general assistance, housing support, and other services available to the general population, but do not receive monthly checks from the government. Some tribes do pay tribal members a “per capita” payment. These are proceeds earned by the tribe and paid out to tribal members in a fashion similar to that of dividends paid to shareholders in a corporation. Treaty-bound services not available to the general public include health and education services.
Myth 2: Natives do not pay income taxes. Native Americans pay taxes like any other group. There are some exceptions, which may include monies earned within reservation boundaries in some states.
Myth 3: All Indians look like the Plains Indian, with a dark complexion, high cheek bones, and brown eyes. Many Natives have intermarried, changing the gene pool and diversifying phenotypes among Native people. Nearly 70% of Indians/Natives are in mixed marriages, whether with Indians/Natives of other tribes and bands or with other racial and ethnic groups. Furthermore, during the Civil War, many slaves that escaped were adopted into tribes and, as a result, there are many Black Indians.
Myth 4: Natives possess knowledge of all Native American experiences across tribes. There is an expectation or myth held by the non-Native “other” for Native individuals to possess knowledge of other Native groups, contemporary, historical, or both. Combined with this false expectation is that an individual Native can speak for other groups. This can present itself as a stressor.
Myth 5: Tribes should share the wealth. This myth is grounded in the assumption that all Indian groups are one. The diversity within Native tribes can be seen in the extent to which there are alliances among groups. Tribes can be compared to corporations, in that, for example, the Ford Motor Company would not assist Chevrolet in times of financial crisis. This myth also serves as an example of how stereotypes are negotiated, building one stereotype upon another, only to develop a set of erroneous assumptions that may drive perception and behavior.
Myth 6: Native families often neglect their children. Native families had been broken historically through forced assimilation strategies. In addition, child care differences and conflicting worldviews contributed to the removal of Native children from their homes and tribes. It wasn’t until the 1970s that this myth was challenged in the courts, with pleas to legislatures to change the adoption process of Indian children. This change was brought about by the lobbying of many tribes and the action of concerned individuals in the federal legislative arenas. The Indian Child Welfare Act (ICWA) became law in 1978 and subsequently was implemented in 1979. ICWA established a new set of strict requirements for child welfare cases and placed authority for Native children with tribes. This ushered in a new era for Indian/Native child welfare. This act changed adoption practices in the United States, giving preference to family and tribal members for the provision of a culturally appropriate living environment.
Health and Psychosocial Concerns
The health status of Natives lags behind all other ethnic groups in the United States. The top 10 leading causes of death, in no specified order, are tuberculosis, chronic liver disease and cirrhosis, accidents, diabetes, stroke, chronic lower respiratory diseases (e.g., pneumonia), suicide, homicide, cancer, and heart disease. In addition, rates of obesity, substance abuse, sudden infant death syndrome, and mental health concerns (e.g., depression and posttraumatic stress disorder) are disproportionately higher among Native Americans. Socioeconomic conditions, including unemployment, lack of economic opportunities, and lack of availability of and access to appropriate health care, influence health status and contribute to high mortality rates. These conditions, combined with geographic isolation, limited access to medical care, high costs, and other barriers, create invisible boundaries that stand between Native peoples and appropriate health care.
Through examining rates of diagnoses, prevalence, and mortality, barriers to adequate health care and far-reaching health disparities are evidenced. For example, the Centers for Disease Control and Prevention reported that Natives are 3 times more likely than Whites to be diagnosed with diabetes, Native American adults are at greater risk than their White counterparts of developing cardiac concerns, and Natives are less likely than Whites to be informed of having hypertension. In addition, Native Americans are reported to be twice as likely to be diagnosed with stomach or liver cancers as White men, and Native women are reported to be 20% more likely than White women to die of cervical cancer.
Although health outcomes are slowly improving for this population, Native Americans experience relatively compromised health, with one of the primary factors being substance abuse. Alcohol-related deaths are 4 to 5 times the national average among Native people, and at least one third of all visits to Indian Health Services are alcohol related. This also influences the number of deaths by accident for this group, both vehicular and nonvehicular accidents.
Crime in Indian Country
Data from the Bureau of Justice Statistics, highlighted in A BJS Statistical Profile, 1992-2002: American Indians and Crime, reveals a wealth of information and statistics about crime in Indian country. For example, American Indians were reported to be more likely to be arrested for aggravated assault than arrested for robbery. Native children under 17 years of age were less likely to be arrested for a violent crime than youth of all races, with the exception of murder. Native adults were twice as likely as their non-Native peers to be arrested for driving under the influence or alcohol violations, and Native youth (i.e., under 17 years) were nearly twice as likely to be arrested than non-Natives for alcohol-related offenses.
Gangs have emerged onto the reservation areas. About 23% of respondents to the 2000 National Gang Survey indicated that they had gang problems on their reservation or Native community. Alcohol and/or drug use was a factor in 51% of the violent crimes against all races. Among victims of violence that were able to describe use by offenders, American Indians were more likely than any other racial group to report an offender under the influence of alcohol or drugs.
The combination of stress, depression, substance abuse, and psychological frustration contributes to the increases of violent and abusive behaviors throughout Indian/Native communities. The rate of violent victimization among American Indian women was more than double that among all other women. Indians/Natives were twice as likely to experience a rape/sexual assault. Violence and resultant trauma can have vast effects on the survivor or bystander. Among the manifestations include child physical and sexual abuse, child neglect, domestic violence, assault, homicide, and suicide. Suicide is 3 to 6 times greater in Indian country.
Indian Child Welfare
Before the institutionalization of the Indian Child Welfare Act (ICWA), displaced Native children had been assigned to care outside of their homes at rates between 5 and 30 times higher than their non-Native peers. Tribes responded to these alarming conditions by demanding more control over the rights to rear their own children and began to advocate for federal policy to support their position on child care. The passage of the ICWA indicated a federal initiative to address one form of institutional discrimination against Native Americans.
There are eight provisions to ICWA, two of which are noted. First, tribes were given exclusive jurisdiction over children who live on the reservations, except in cases in which federal law already has designated jurisdiction to the state. Second, agencies that place children must provide culturally appropriate services to Native families before placement occurs. The provision of ICWA becomes more complicated when the out-of-home care takes place in urban settings, where access to culturally appropriate services may be limited. Presently, American Indian children are placed in care outside of the home 4 times more often than are non-Indian children.
Considerations of Healthcare Services
Health disparities among Native Americans have been related to cultural mistrust, geographic isolation, and socioeconomic factors. For example, through the 1970s, the practice of sterilization without consent was not uncommon. Such behaviors, enacted primarily by Indian Health Service (IHS) personnel and other governmental agencies, have engendered distrust for some healthcare providers among Native Americans. In addition, urban Indians are geographically dispersed in comparison to other populations, which may compromise their access to tribe-specific health-related information and services.
There are unique considerations relevant to receiving health care services and programming on and off the reservation. On-reservation programming is provided by the IHS generally, under the Behavioral Health Program, or contracted by the tribe with IHS or other providers. Health care available off the reservations is funded at only about 2% of the IHS budget in urban areas. This leaves the majority of Indians without access to adequate health care.
Urban health and mental health services are not as clear-cut. Only about 2% of all IHS funding goes to urban Indian programs, where up to 60% of all Natives live. According to the Surgeon General’s report in 1999, only 20% of Natives reported access to IHS clinics, most of these found on reservations. Medicaid is the primary insurer for about 25% of this population, and only 50% of Natives have employer-based insurance coverage, compared with 72% of Whites. Twenty-four percent of all Natives do not have health insurance, compared with 16% of Whites. When scarce resources are needed for survival, mental health becomes a luxury item.
Mental health needs among Native populations vary, yet there appears to be some commonalities across tribes. Similar rates of lifetime diagnosis in Native populations have been reported concerning alcohol dependence, posttraumatic stress disorder (PTSD), and major depressive episodes. For example, the Surgeon General’s Report of 2000 stated that depression ranged from 10% to 30% among Native populations.
Effects of Trauma
Considerations of the profound effects of direct, vicarious, and historical trauma on Native peoples have implications for substance use, violent behaviors, and depression. The many precipitating factors of PTSD include service in combat zones; exposure to violent accidents, homicides, and suicides; sexual victimization; and poverty and homelessness. The higher rate of traumatic exposure results in a 22% rate of PTSD for Native peoples, compared with 8% in the general population. Moreover, the Vietnam Veterans Project found lifetime prevalence of PTSD to be from 45% to 57% among Native veterans, rates significantly higher than among other Vietnam veterans. Prevalence rates for current alcohol and drug abuse or dependence among Northern Plains and Southwestern Vietnam veterans have been estimated to be as high as 70% compared with 11% to 32% of their White, Black, and Japanese American counterparts.
The rate of violent victimization of Natives is more than twice the national average. Given the exposure of this population to potential stressors beyond the “norm,” mental health professionals must be versed in PTSD and potential referral sources that may include traditional healing ceremonies or activities.
Values and Mental Health
Cultural values among Native people are, among themselves, very diverse. However, when considered as a collective, Native cultural values tend to contrast significantly with individualistic and dualistic orientations of Western psychology. In Indian country, traditional groups view life as a function of the interconnectedness of all things, and behavior is considered to be motivated through the interconnections with others. In these philosophies, balance among the reciprocal effects of actions and changes in the entire system leads to wellness. Furthermore, the interplay of these worldly and otherworldly (i.e., spirited) systems creates a whole. Attention to both of these systems often is desirable to effect long-lasting and effective change for clients, such that therapeutic goals include balance among individual, spiritual, and community systems.
Effective interventions are dependent upon many factors. Counselors’ attention to clients’ levels of acculturation facilitates effective care. It is also critical for mental health professionals to have an understanding of the Native family and extended family systems and clients’ roles in these systems. In urban and reservation settings, the therapist needs to be known and trusted in the community. This can be facilitated by attending open social gatherings and attending local school functions.
There are traditional interventions that have been found to work across settings. These include the talking circle, sweat lodge ceremonies, smudging ceremonies, and others. It is recommended that the non-Native therapist seek Native spiritual leaders with whom to develop relationships so that they may later refer clients for spiritual assistance. Non-Native therapists can work with clients on therapeutic goals while learning about clients’ cultural experiences through the therapeutic process.
- Beals, J., Novins, D. K., Whitesell, N. R., Spicer, P., & Manson, S. M. (2005). Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: Mental health disparities in a national context. American Journal of Psychiatry, 162, 1723-1732.
- Centers for Disease Control and Protection, Office of Minority Health & Health Disparities. (2005). Health of American Indian or Alaska Native Population. Retrieved from http://www.cdc.gov/nchs/fastats/american-indian-health.htm
- Evans-Campbell, T. (2006). Indian child welfare practice within urban American Indian/Alaskan Native American communities. In T. M. Witko (Ed.), Mental health care for urban Indians: Clinical insights from Native practitioners (pp. 33-54). Washington, DC: American Psychological Association.
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- Perry, S. W. (2004, February). A Bureau of Justice statistical profile, 1992—2002: American Indians and crime. Washington, DC: U.S. Government Printing Office.
- U.S. Census Bureau. (2006). We the people: American Indians and Alaskan Natives. Washington, DC: U.S. Government Printing Office.
- U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity, supplement to mental health: A report to the Surgeon General. Rockville, MD: U.S. Government Printing Office.
- Witko, T. M. (Ed.). (2006). Mental health care for urban Indians: Clinical insights from Native practitioners. Washington, DC: American Psychological Association.