The white man does not understand the Indian for the reason that he does not understand America. He is too far removed from its formative processes. The roots of the tree of his life have not yet grasped the rock and soil. In the Indian, the spirit of the land is still vested, it will be until other men are able to divine and meet its rhythm. Men must be born and reborn to belong. Their bodies must be formed of the dust of their forefather's bones."1
Today's native Americans represent a legacy of tragedy that so often visits the conquered. This history has been documented by many authors through the years.2'5 In that they are the most frequently arrested of any American ethnic minority group, and reservations are under tribal and federal jurisdiction, a disproportionate number of native Americans find their way to Bureau of Prison institutions.6 In and out of prison, such client populations often require additional knowledge, skills, and understanding on the part of care providers if their mental health needs are to be adequately met.
The 1980 census identified 1 .5 million native Americans, twice as many as were identified during the 1970 census.7 While only a third of these Indians live on reservations, approximately another third living between urban areas and reservations return frequently to reservations to visit. The remaining third live exclusively in urban centers.8 There are 511 federally recognized tribes and 365 additional tribes recognized by individual states speaking nearly 300 different languages. Together, native Americans represent a heterogenous population with a cultural diversity that defies reductionistic grouping or simplistic understanding.9
In 1980 the median age of the native American population was 20.4 (17.9 for Alaska natives) as compared with 30.3 years of age for the US population in generai. This appears to be due to a birth rate that is roughly twice that of the rest of the country.10 However, the death rate, particularly among the young, is also extraordinarily high: infants and children account for 20% of all deaths, with the former rate being the highest of any American ethnic group. The death rate of native Americans ages 5 to 24 is at least twice as high as that of the rest of the populations of the US.10
In 1 970 the average annual income for native Americans living on reservations was $900, and $2,000 per year for urban native Americans.8 This is the lowest average income of any identified ethnic group in the country. Currently, unemployment ranges from 20% to more than 70%, with a "stable" unemployment rate of approximately 30% being reported on most reservations. A Senate hearing revealed that 52% of urban native American youth and 80% of reservation youth abused drugs or alcohol at moderate to severe levels. This was contrasted to 23% of urban non-native American adolescents." In urban areas, native Americans are arrested for crimes while under the influence of drugs or alcohol four times as often as blacks and ten times the rate of whites.12
Poverty, unemployment, and substance abuse go hand in hand with substandard housing, malnutrition, a high rate of illness, suicide, and limited education. The reported educational attainment of native Americans 25 years or older is 9.6 years, the lowest educational average reported among all American ethnic groups.13
For the 20th century native American, in addition to the social, financial, health, and educational problems, psychological problems are also pervasive. Alienation, depression, anxiety, adjustment reactions, behavioral, and other emotional problems are well described in professional literature.10,14
Mental health care providers often fail to treat the urgent needs of this unique population14; most native Americans turn to informal or formal community based treatment (ie, medicine man, religious ceremonies) for help. Those who participate in more conventional treatment are typically referred by their physicians. It has been estimated that up to 50% of their health needs are accompanied by mental health needs. Of those who are seen by mental health care providers, most drop out after their first visit.10 Traditionally taught psychiatric diagnostic and treatment strategies do not appear to be reaching much of the native American population.
In spite of significant inter- and intra-tribal differences, numerous researchers have pointed out cultural similarities among native Americans. Most native Americans perceive their world in a holistic fashion, utilizing intuition, metaphor, and visual means of representation. Thinking tends to be circular and inductive. Communication styles and patterns differ from those of the dominant cultures where students are trained in linear thinking: logical and analytical or deductive reasoning, auditory processing, abstract thought conceptualization, and specific interpersonal and language skills are necessary if academic success is to be obtained. By virtue of their education and training within the dominant culture, psychiatrists are not prepared to meaningfully engage most native Americans in psychotherapy. The tendency to view those with differing world views as pathological is heightened when the viewer is unfamiliar with the tenets of other cultures.
Foundational to psychiatric intervention is knowledge of a person's underlying world view and assumptions. For example, Anglo-Americans perceive time and space as a measurable, ordered entity. Individuals who cannot schedule or organize their time are seen as not fully functional. In the popular vernacular, we "plan ahead, know where we are going, and keep things straight." Such a cultural pattern may be so entrenched that we are not even aware of it and thus fail to question its validity.15 Many people locate themselves along a hypothetical ribbon of time that is developmental in scope and measurable against the achievements of others. Expectations between individuals differ considerably.
Time for the native American is much different, with focus on the present ; there is not an orientation as to future time. The individual is encouraged to make adjustments to the environment until all of the necessary elements are present, at which time the person is to respond to and appreciate the opportunity rather than make it happen.
There are also significant differences in the use of eye contact, body language, verbal expressions, and the frequency, pace, and rate of speech between cultures. If not appreciated, these may seriously alter perceptions during history taking and mental status examinations. For example, when reviewing a patient's history, we look for trends and patterns in past behavior. From these, we look ahead and project our findings to future behavior. Furthermore, we make a prognosis in regard to realistic goals and objectives that can be attained due to therapeutic intervention. In order to do this, we process and interpret the quality of our rapport and the accuracy of our findings according to subtle and overt visual and behavioral cues.
A general review of the native American culture base and world view demonstrates that while AngloAmericans value planning and sequencing, native Americans value negotiation and adjustment. Abuse among native American children is relatively rare: rates are 6.5 per 1,000 boys and 2.7 per 1,000 girls, compared with 13 per 1,000 white boys and 15 per 1,000 white girls.16,17 This is relevant in that native American youth are born into a circle of acceptance and care from their family, tribe, and earthly surroundings. Gatherings, whether formal or informal, include circular seating patterns, dances, and sweat ceremonies. Many cues, both philosophical and overt, teach them that their world is round instead of organized in linear progressions. Their surroundings provide sustenance and resource as well as obligation and responsibility. The ecosystem is to be adjusted to by reciprocal negotiation. A native American is both a part of and surrounded by nature. This nature is not subjected to a plan determined by humans. While humans are perceived as caretakers and thus responsible for their own behavior (anything you can effect change in, you have a responsibility toward), they are not perceived as the "masters" of the world. Perhaps this is more appropriately articulated in the words of Luther Standing Bear:
We do not think of the great open plains, the beautiful rolling hills, and winding streams with tangled growth as wild. Only to the white man was nature a wilderness and only to him was the land infested with wild animals and savage people. To us it was tame. Earth was bountiful and we were surrounded with the blessings of the Great Mystery. Not until the hairy man from the east came and with brutal frenzy heaped injustices upon us and the families we loved was it wild for us. When the very animals of the forest began fleeing from his approach, then it was for us that the Wild West began.1
For the Sioux and Hopi, two sample tribes, the concept of mental health involves well being beyond the absence of sickness or discomfort.18 Peacefulness and strength displayed by self-control and adherence to traditional values are actively pursued in these cultures to the end of being healthy.14,19
These values are common in various forms with most native Americans and are particularly guarded by the traditionai healer, who is also the keeper of legends. Stories in the form of metaphors are often presented to a person, both in a healing capacity and for a preventive purpose. In this way the individuals are allowed the maintenance of personal dignity while still hearing possible solutions and causes for their particular dilemma. Stories are repeated many times over the course of a person's life because the values and instructions are viewed as timeless. Although shared with persons who are perhaps "losing their way," they are never imposed. Treatment is conducted at the individual's own pace in the supportive presence of the identified healer and often with other caring group members. These informal groups include family, friends from the tribe, and friends from the broader Indian community.
During traditional sweat ceremonies the participants sit in a circular fashion and speak in turn. Prayers are usually for others. Confession, when it occurs, is m a somewhat ritualized nature followed by collective conversation. This in turn is followed by reassurance and support from the group. Thus, the individual is protected from embarrassment or humiliation in that all others are participating in the same ritual. The strong bond of the individual to the group results in little coercion directed at those who are straying, yet offers frequent, ready, and willing response by the group to the person needing help.
Among native Americans is a taboo against staring at another person during formal conversation, which would be viewed as establishing dominance. Such an act of dominance has little value in the egalitarian circle of the native American harmony ethic.20
Native American values of conformity to the group, bravery, focus on the "now" element of time, individual freedom, reverence for nature, respect for elders, and noninterference can either be utilized resourcefully by the mental health professional responding to treatment needs or be ignored to the detriment of all concerned.10,14,18,19-21,22 These values are incorporated for most native American tribes in rituals, legends, stories, dances, and everyday behavior so as to be brought to a person's attention in subtle and overt ways repeatedly throughout his lifetime. Repetition of metaphorical stories and a circular approach are both elements common to informal native American mental health treatment strategies.
Traditional psychotherapeutic approaches, whether individual or group, may not work well with this population. LaFromboise describes the "incompatibility between conventional approaches and indigenous approaches."14 Native Americans may only approach professional services when their informal community resources become unavailable.
Engaging native Americans in treatment usually means finding a method of gathering family, relations, persons from their communnity, or other native Americans in either formal or informal meetings. Once gathered, the therapist can work through the traditional healer in the sense of learning from his style and watching carefully the particular social and nonverbal patterns of behavior. If thrust into the role of healer, the therapist can address issues metaphorically through the use of stories in examples and provide answers indirectly to the problems perceived to be in the lives of the group members. Traditionally, the persons in the group will speak once, beginning with the oldest, most respected person and continue until each has had an opportunity to express his thoughts, feelings, and ideas relevant to the conversation at hand. The therapist thus opens the session, initiates individual speech around the circle, waits until all who wish have spoken, and then makes closing remarks.
In a formal Indian gathering, each person is allowed "space" to speak; a 45-second to two-minute wait before another person speaks is the norm. Hence, if one is invited to speak but has not yet begun or is taking a long pause in the midst of a statement, no one will interrupt. Each individual is given time to collect his thoughts and then to proceed at his own pace. Speech is not hurried. If the individual is not inclined to speak it is not demanded, although the individual is given at least two minutes to decide. Prompts or verbal feedback should not be offered as that may be perceived as intrusive.
The above description contrasts with much of contemporary psychiatry, which is heavily grounded in an Aristotelian world view that promotes linear thinking, weakens the sense of connectedness relative to time and space, encourages competing dualisms, and weakens community.14*23 Current American culture also emphasizes materialism, prosperity, and individualism independent of responsibility to the group, and freedom and autonomy for the privileged (either through education or financial standing) class. Often this value system leads to alienation and narcissistic selfabsorption.14-24
While there are admirable values in the native American style and traditions, the historical means of maintaining good mental health, to a degree, have broken down. Loss of the former way of life that supported their particular world view has had its impact. For some tribes this occurred suddenly and drastically within 30 years of their first significant contact with whites. Cultural destruction occurred more rapidly than functional cultural change and assimilation.2-5
The clinical world view of most health care professionals assumes the propriety of their sometimes unexamined personal values and world view. Individualistic insight approaches that ignore the larger native American world view with its emphasis on community and interwoven spirituality may lose credibility for the mental health service provider and interfere with assisting the native American client in resolving personal or family conflict.
When possible, psychiatric care providers are encouraged to utilize intact relationships within the formal and informal network of other native Americans in order to treat identified psychiatric problems. When this is not possible, creatively integrating some of the cultural values, world views, and styles discussed will often assist in building therapeutic rapport and finding culturally acceptable means for the patient to receive what the therapist has to offer.
1 . Chief Luther Standing Bear: Land of thv Spotted Eagle. Lincoln, Neb, University of Nebraska Press, 1978.
2. Andrist RK: The Long Death, The Last Days of the Plains Indian. New York, MacmiIIan Cortipany, 1964.
3. Matthiessen P: Indian Country. New York, Viking Press, 1984.
4. Deloria V Jr: We Talk, You Lisien, New Tribes. New Turf. New York, MacmiIIan Company, 1970.
5. Steiner S: The New Indians. New York, Dell Publishing Company, 1968.
6. Crime in The United States i972: Uniform Crime Reports. US Department of [ustice, Federal Bureau of Investigations, US Government Printing Office, J976.
7. i980 Census of Population; Characteristics of the Population, US Summary. PC 80-1 -Bl, Washington, DC, US Department of Commerce, Bureau of the Census, !983.
8. 1970 Census of the Population. PC2-IF. Washington, DC, US Department of Commerce, Bureau of the Census, 1973.
9. Manson S, Trimble J: American Indian and Alaska-native communities: Past efforts and future inquiries, in Snowden LR (ed): Reaching the Underserved: Mental Health Needs of Neglected Populations, Beverly Hills, Calif, Sage Publishing Company, 1982.
10. Yates A; Current status and future directions of research on the American Indian child. Am f Psychiatry 1987; 144:11351142.
11. Indian Juvenile Alcoholism and Eligibility for BIA Schools. Senate Hearing 99-286, US Government Printing Office, US Senate Select Committee on Indian Affairs, 1985.
12. Jepsen GF, Strauss IH, Harris VW: Crime, delinquency and the American Indian. Human Organization 1977; 36:252-257.
13. Brod RL, McQuiston JM: American Indian adult education and literacy: The first national survey, fournal of American Indian Education 1983; 1:1-16.
14. LaFromboise T: American Indian health policy. Am Psychol 1988; 43(5) : 388-397.
15. Toelken B: World View, the University Establishment and Cultural Annihilation. To be published.
16. NagiS: Child Maltreatment in the United States. New York. Columbia University Press, 1977.
17. Oakland L, Kane RL: The working mother and child neglect on the Navajo reservation. Pediatrics 1973: 51:849-853,
18. MedicineB: New roads to coping: Siouan sobriety, in Mason S (ed) : New Directions in Prevention Among American Indian and Alaska Native Communities. Portland, Ore, National Center for American Indian and Alaska Native Mental Health Research, 1982, pp 189-212.
19. Trimble |: Value differentials and their importance in counseling American Indians, in Peterson P, Draguns J, Lonnier W. et al (eds): Counseling Across Cultures. Honolulu, University Press of Hawaii, 198J, pp 203-226.
20. French L: Social problems among Cherokee females: A study of cultural ambivalence and role identity. Am / Psychoanal 1976; 36:163-169.
21. Byrde JF: Modern Indian Psychology. Verm'illion SD, Institute of Indian Studies, University of South Dakota, 1971.
22. Metcalf A: From schoolgirl to mother: The effects of education on Navajo women. Social Problems 1976; 23:533-544.
23. Spence G?: Achievement American style; The rewards and costs of individualism. Am Psycho! 1985; 40:1285-1295.
24. Bellah RN, Madsen R, Sullivan WM, el al: Habits of the Heart. Berkeley. Calif, University of California Press, 1985.