FAST FACT

The terms American Indians, Native Americans, and First Nations refer to the descendants of indigenous people who inhabited the North American continent for centuries before the arrival of European settlers. They were organized into tribes and nations. Today there are over 560 federally recognized indigenous groups in the United States.  They each maintain long-held cultural practices that are influenced by regional, geographical and socio-economic indicators that vary among them, and the cultural practices of these groups cannot be stereotyped into any one mold (LaFromboise, 1988; Reynolds et al, 2006; Urban Indian Health Commission, 2007; Yurkovich & Lattergrass, 2008; US Census, 2007).

Demography and immigration

Before the Europeans came to the Americas, American Indians and Alaska Natives (AI/AN) inhabited North America.  In fact, scientists date the migration of AI/AN to more than 10,000 years ago, before the end of the last ice age (Encarta 2009).  AI/AN developed into unique tribes, dispersed throughout the continent, and adapted to the environment. In Alaska, natives learned to hunt, fish, and effectively combat the harsh climate. Throughout Southwestern deserts, tribespersons constructed multilevel adobe housing and grew corn. Due to federal policies and oftentimes coercion, many AI/AN peoples relocated from their native lands to reservations similar to the ones that exist today (CultureCard, 2009).

In 2007, the U.S. Census Bureau estimated that 4.5 million people in the United States were AI/AN alone or in combination with one or more races; this represents 1.5% of the total population.  In 2000, of the 4.3 million people that reported similarly, about 56% were exclusively AI/AN (U.S. Census 2000). An estimated 7 million Americans claim descent from an Indian ancestor and retain a sense of identity and interest, despite not having ties to Native communities (Champagne, 1999).

While the median age for the general U.S. population was 36.4 in 2006, the median age of the AI/AN population was 31 (U.S. Census, 2007). There are 1.3 million AI/AN age 18 and younger compared to the 352,000 aged 65 and older (U.S. Census, 2007).   The 2000 Census found a four-year median age disparity among American Indians living on reservations (25 years) and those living elsewhere (29 years) (GMAC 2008).

The U.S. government recognizes 562 unique tribal cultures, and there are an additional 245 non-federally recognized tribes (CultureCard, 2009).  Approximately 60% of the AI/AN population lives in urban areas with less than half (1.9 million persons) living on reservations or other land trusts (Yurkovich & Lattergrass, 2008).  Most reside in the western states (Champagne, 1999). An estimated 7 million Americans who claim descent from an Indian ancestor, do not have enduring ties to Native communities, but retain a sense of identity and interest (Champagne, 1999).

Most AI/AN reside in the western states, with a sizable representation in every Western state (Champagne, 1999). The Western states of California, Nevada, Idaho, Oregon, Washington, Utah, Wyoming, and Colorado have an AI/AN population of between 1.5 and 4.9 percent. The remaining three Western states of New Mexico, Arizona, and Montana have populations of AI/AN between 5.0 and 12.8 percent (U.S. Census 2000).

Starting in the 1970s, gaming became a viable source of income for many American Indians living on economically-unproductive land. The Western states of California, Nevada, Oregon, Washington, Idaho, Montana, Colorado, New Mexico, and Arizona have class III tribal gambling, and the remaining Western states of Utah and Wyoming have tribal presence with various forms of gaming (NIGA 2009).

Although a get-rich-quick stigma has been placed on American Indian gaming, only about half of the federally recognized tribes operate any gaming business and nearly 50% of American Indian families are still below the poverty line (The Wild West 2009).

According to the 2004 Census, the most prominent American Indian groups were the southeast Cherokee (with 331,491), the southwest Navajo (with 230,401), the Midwestern Chippewa (with 92,041) and the southwest Pueblo (69,203). The largest tribal group in Alaska is the Eskimo, with 35,951 people (Census 2004).

In New York State, 82,461 individuals, representing less than 1% of the state population, self-identify as Native American Indians (U.S. Census Bureau, 2000). 27,000 live in New York City (aich.org). Population data has shown an increase in recent years possibly due to improved data collection, a greater willingness by Native Americans to identify with their heritage, higher birth rates and reduced infant mortality (Champagne, 1999). Projections through the Census Bureau’s American Community Survey raise the count to 169,000 (Census Bureau, 2007). They reside mostly in large cities and suburban towns blending into general society; only one-fifth live on Indian reservations. Additionally, through inter-marriages, many no longer regard their Indian roots as their primary background. There are too few Alaskan Natives living in New York State for the Census Bureau to report data.

New York State Indian Tribes in Colonial Times

New York State Contemporary Indian Reservations

Images from www.native-languages.org

Prevalence rates of mental illness

Native Americans appear to be at higher risk for mental illness than other cultural groups in the United States.  They have a disproportionate burden of mental health and substance abuse problems including high suicide rates, and co-morbid alcohol and mental health disorders (Nelson et al, 1992; Caldwell et al., 2005; Johnson & Cameron, 2001).  Suicide is the second-leading cause of death among AI/AN people age 10 to 34 (CultureCard, 2009).  Available evidence suggests that mental illness, mental dysfunction, or self-destructive behavior affects approximately 21% of the total AI/AN population, costing an estimated $1.07 billion and incalculable human suffering (Duran et. al, 2004).

Precise prevalence and utilization rates in mental health care are oftentimes confusing and misleading due to limited research sampling and methodologies (Choi et al., 2006), and Native Americans are routinely omitted from many studies. Two major US prevalence studies—the Epidemiologic Catchment Area Study1 and the National Comorbidity Survey 2—do not report data on Native Americans, or indicate that statistics on this group are difficult to specify (Duran et al., 2004). In the National Healthcare Disparities Report, only 42% of the measures could be used to assess mental health disparities among Native Americans (Moy et al., 2006).

Major problems for Native Americans include chronic alcoholism (Brod, 1975), binge drinking (Champagne, 1999), and heavier drinking and substance abuse among adolescents compared to other ethnic groups in New York State (Barnes & Welte, 1986; Schinke et al., 1988). A study of three large Native American families found 70% of their members had a lifetime diagnosis of alcoholism; another study noted adolescents were at high risk for co-morbidity (Champagne, 1999). A high proportion of battered Native American women have shown increased stress, anxiety and depression (Norton & Manson, 1995, online 2005), pathological gambling (Elia & Jacobs, 1993), spousal abuse, fights, and crime. Suicide rates among males in the United States are highest for AI/AN (SAMHSA, 2002). They are also higher among AI/AN adolescents than other ethnic groups (Manson, 1982).

Cultural views of mental illness

Traditionally, AI/AN believed all illness was caused by demoniacal interference, malignant spirits, sorcery, or failure to perform an important ritual. The cure was to call in the shaman, or medicine man, who would invoke different magical spells, formulas, native artifacts, tobacco smoke or natural botanical drugs to drive out the evil spirits causing the illness (White, 1979).  There was no distinction between the physical and mental life.

Contemporary thinking correlates mental illness as a reaction to the history of forced oppression and trauma faced by Native Americans following the arrival of European settlers. The cries of westward ho and manifest destiny in American history brought warfare and new strains of physical disease to many tribes, and decimated their populations. The trauma suffered by generations of Native Americans has contemporary effects in both the community as well as the individual consciousness. Some literature points to a developmental history of psychological distress that has resulted from genocide, ethnic cleansing, and forced acculturation; examples of which can still be found in contemporary US society (Whitbeck et al., 2004).

Impact of cultural values on the use of mental health services

American Indian culture is holistic in nature. In this tradition, the physical, mental (cognitive), emotional, and spiritual aspects of a person are typically perceived as one and largely considered inseparable; the mind–body split of western thought is averse to Native Americans (Yurkovich & Lattergrass, 2008). Indigenous people, in general, value group membership, natural connections to spirituality, honor, wisdom of the elders, and respect for the environment as a necessary component for sustaining future generations. Community well-being and group success are the primary goals of its members (LaFromboise, 1988). Native Americans highly value spirituality and trustworthiness. Communal approaches are favored as an approach to intervention, rather than the dyad one-on-one approach of Western therapy (Calabrese, 2008).

Native American people typically refrain from in-depth, one-to-one disclosure within clinical settings.  Individual counseling is generally not as successful as group counseling.  In mental health service provision, trustworthiness can be addressed by demonstrating authenticity, respectfulness, concern, visible signs of listening behavior, some degree of self-disclosure, and slow pace (Lokken & Twohey, 2004).

Family Role Family structures and family member roles are not homogenous, vary among tribes, and are largely influenced by proximal influences and individual responses to the dominant culture.  Native American families incorporate a range of cultural practices and acculturation patterns, with some families strictly following tribal traditions and avoiding mainstream cultural practices, and others incorporating mainstream cultural practices at differing degrees (Barrios & Egan, 2002).

In general, most Native Americans develop and socialize within an extended family approach that serves as one of the principle protective factors in Native American mental well-being. Extended family is a network of relationships, distinct from one’s clan or tribe, in which members affect one’s identity and role in the community, transmit culture, and conserve family patterns. In many Native communities, growing up in the homes of different extended family members is viewed as a sign of positive social relations for the child and as an opportunity to develop in multiple supportive environments (Caldwell et. al, 2005).  The influence of the community plays an additional significant role in well-being. Extended family, community, and tribal relationship often takes precedence over individuality and is usually well-established. A strong sense of belonging comes from an emphasis on cultural ties and social relationships, as well as a sacred sense of connection to one’s ancestry and tribal history (Long, 2006). The family typically includes a multigenerational household and concomitant elder or infant care- a practice that is rooted in cultural beliefs (Adelson, 2008).

In traditional AI/AN culture, marriages were arranged in ways that best suited the survival and well-being of the tribe, although couples could reject the proposed marriage. Monogamy was the general rule, but a few tribes practiced voluntary polygamy. Men and women had their specific duties but their roles had equal importance. Some tribes were matriarchal in structure, inheritance, and familial lines (White J, 1979).  

Women  Native American women have a significant role in most First Nations social systems.  Specifically, the literature has emphasized the importance of elder Native American women in the transmission of culture and values and as leaders in their clans, tribes, and nations (Barrios & Egan, 2002).

Native womens’ power is manifested in their roles as sacred life givers, teachers, healers, doctors, and seers.  In many instances, the health of their communities depends upon them (Walters et al., 2006). 

Social Class  AI/ANs are sensitive to their lower socio-economic status.  Many feel that in their interaction with governmental agencies and mental health facilities they may be looked down upon.

Conversely, many Natives speak English, are well educated, and aspire to professional careers (Champagne, 1999).

Shame/Stigma  AI/AN culture stigmatizes mental illness. In practice, they may need assurance that confidentiality will be protected (Long, 2006).

Work  Indigenous people value work and being employed although unemployment rates are typically higher within reservation communities than in urban areas. Unemployment was about 12%  in 2007 (DeVoe et al., 2008), while the national unemployment rate was 4.5% (Bureau of Labor Statistics, 2008).

During the 1960’s The Indian Relocation Program was a central part of the Bureau of Indian Affairs (BIA) that intensified efforts to move American Indians from reservations into eight metropolitan areas of the United States where more jobs were available to better provide employment assistance and vocational training. A common outcome of the program was disrupted cultural ties (Bell, 2005).  As young people move into urban areas where there are jobs, tribal and cultural ties are broken (Fox et al., 2005).  In time, social structures and other supportive services were created in order to sustain a cultural sense of kinship.

In contrast, gaming and casinos have provided opportunities to increase rates of employment since tribes tend to hire their members first.  As tribal communities become more affluent due to the employment opportunities afforded by new economic infrastructures on their territories, money management skills consistent with tribal tradition are found to be increasingly successful (Long, 2006).

Spirituality, religion and traditions  Native American spirituality, similar to descriptors of the population itself, is not homogenous, varying by locations and tribal affiliations. Most, however, have strong connections to the natural world and see spirituality as intertwined and inseparable from overall wellness. Indigenous worldviews recognize the interdependency between humans and nature, the physical and spiritual worlds, their ancestors and future generations (Walters et al., 2006).  Spirituality is crucial to wellness and is visible in contemporary efforts to reclaim lost or forgotten traditions.  Native beliefs and approaches are cited in the literature as effective means of prevention, recognition, and treatment of mental illness (Beauvais, 1998).

Native American elders who bore the brunt of assimilation policies throughout post-colonial contact were clear that the youth should continue or return to the beliefs and activities that sustained their ancestors. Thus, a return to tradition includes encouragement to youths to learn the language and take part in spiritual activities while learning ceremonies, stories, traditions, and skilled handwork (for making dress, ceremonial, and funerary items), that represent and maintain their communities (Fox et al., 2005).

Until the passage of the Indian Religious Freedom Act in 1978, many traditional AI/AN practices were illegal and kept secret (CultureCard, 2009).  In addition to traditional belief systems (e.g., peyotism, sun dances), there are numerous forms of organized religion, including Christianity, Catholicism, Hinduism, as well as non-believers, among most AI/AN communities. Indigenous communities that practice according to custom more likely refer to a “belief system” as opposed to an approach based on organized religion.

Communication Styles  AI/AN people communicate a great deal through non-verbal gestures.  Accordingly, clinicians must observe carefully to avoid misinterpretation of non-verbal behavior.  Additionally, AI/AN people often use humor to convey truths that are painful.  They may also tell stories (traditional or personal) in order to make a point.  Asking for clarification about sensitive topics is considered invasive (CultureCard, 2009).

Mental health care seeking patterns

Sources and types of formal help
Most Native Americans see the potential benefit in counseling only when it is entered into freely and not mandated. Resistance to entering formal treatment is often culturally rooted in concerns about past governmental intrusions into Indian life (LaFromboise, 1988).

In general, schools, hospitals, and health clinics represent the primary sources of formal help (Bell, 2005). Overall, studies of Indigenous groups from various regions of the continental US report that about thirty percent are less likely to seek help from formal settings compared to national samples of similar/like conditions among other groups (Beals, et. al, 2007; Evans-Campbell et al., 2006; Urban Indian Health Commission, 2007). Women who are victims of domestic violence tend to seek help from more formal settings; probably due to the shame and embarrassment associated with this type of violation and reluctance to be open about the violence in their own local communities (Evans-Campbell et al., 2006).

The federal government and some state governments have specific moral and legal rights and responsibilities toward Native Americans (Weaver, 1998). The Indian Health Service of the Bureau of Indian Affairs has a primary obligation to provide for the physical and mental health of Native Americans. However, their programs are underfunded and lost in a confusing maze of federal, state and local programs concentrated on Indian reservations (WICHE, 1998).

Sources and types of informal help
Research suggests that American Indians prefer to talk with a significant other about personal concerns rather than a counselor, depending on the structure of their helping network and the nature of the problem (LaFromboise, 1988).

In some cases, families find it difficult to rectify mental and physical disability from an AI/AN cultural framework with the perspective of the non-Native treatment provider. In this case, families may delay their efforts to access contemporary treatment in favor of seeking help from tribal healers and other community supports. (Nichols & Keltner, 2005) Yurkovich and Lattergrass, (2008), argue that cultural context, or that context within which a person is raised, inevitably affects a person’s perceptions of health and wellness. Perception of health care providers as lacking understanding of their cultural patterns dissuades many from seeking formal treatment.

In New York City the volunteer-developed American Indian Community House on lower Broadway, an educational and support service, has a Behavior Health Department that provides a support group in alcoholism and substance abuse issues (aich.org).

Mental health service utilization challenges

Access  The Indian Health Service (IHS) is the Federal agency primarily responsible for providing health care to most Native populations. However, only 20% of American Indians report access to IHS clinics, which are located mainly on reservations. In New York State services are provided through an office in Syracuse.

The IHS’s human service delivery system on rural reservations is often limited to an acute crisis-oriented outpatient service model that does not meet the needs of persons with persistent mental illness. Hence, the reduced availability of services on rural reservations likely contributes to elevated states of mental illness, and ultimately resulting in higher utilization rates of more costly services (Yurkovich & Lattergrass, 2008).

Financial barriers  Medicaid is the primary insurer for twenty five percent of AI/ANs. Only about fifty percent of AI/ANs have employer-based insurance coverage, compared to seventy two percent of Whites. 31% of people who reported they were AI/AN and no other race lacked health insurance coverage compared to 16% of the U.S. population (US Census, 2007). This figure does not include those of mixed race.  The lack of accurate population size estimates results in levels of  funding and the provision of services that are insufficient to provide for those in need within AI/AN communities (Snipp, 2005).

Retention in treatment  Retention is directly related to cultural competence within service provision structures (Cohen et al., 2003). Treatment programs or interventions that address AI/AN clients’ from their own cultural perspectives, retain a culturally competent staff, are able to accept the inclusion of alternative and traditional healers in treatment efforts have higher success rates for AI/AN treatment completions (Fox et al., 2005). Programs are most effective when providers see their approach as “working with communities” rather than “doing for” the individual or group (Trickett & Espino, 2004).

Clinicians, particularly those in urban settings, can expect that First Nations clients will sometimes not be available for treatment-  sometimes for weeks at a time- since many often return “home” to their reservations. Most often these clients return to reconnect with family, attend ceremonies that can last for days, or to spiritually re-charge. Clinicians experiencing this should bear in mind that in some Indigenous territories, telephone service is not readily available or the location and expectations of the ceremonial participation making phone contact to report non-attendance highly unlikely.

Language barriers  At the beginning of European colonization, Native Americans spoke between 200 and 300 distinct languages, nearly half of which are now extinct. The remaining languages today are spoken mostly by the elderly (Champagne, 1999).  The website native-languages.org classifies 25 language groupings and 800 surviving Indian languages within these groups, spoken by approximately 500,000 AI/ANs who live in the US and Canada.  Because the rest of the population does not speak an AI/AN language, the transmission of cultural beliefs is diminishing. Literacy in a Native language is now a high priority for contemporary tribal nations (Champagne, 1999).  Most contemporary AI/ANs speak English. Efforts are underway to teach native languages to Indian youth to prevent the complete extinction of these colorful languages.

Language barriers are most likely to be experienced when working with elderly First Nations clients (Kreig et. al, 2007) who need interpretive services. In some instances, educational/reading level, treatment strategies and methodologies exceed the Native clients reading and verbal communication skills, as formal education is regarded less important than meeting the immediate needs of the family and community. Indian languages lack terms for psychological conditions such as anxious/anxiety or depressed/depression (SAMSHA, 2002). 

Location/time barriers  Agencies do not typically maintain mental health services in close proximity to Indigenous population centers of Native Americans.  Many offer restrictive hours of operation, which do not accommodate working individuals or mothers with children.

Specific age/gender group problems

Youth
Native American youth are more likely than their North American peers to report poor health. Several studies have concluded that the harsh conditions reported for many AI/AN youth, as a result of their socioeconomic status, affects their mental health. According to results from the AI Adolescent Health Survey, a 15-state, cross-sectional survey of middle schools and high schools on reservations, of 13,377 AI respondents aged 12-18 years, 22% reported fair or poor health. These respondents were equally or at least two times more likely to have attempted suicide, to have failed in school, to abuse drugs, to have a poor body image, and to have been physically or sexually abused than those students who rated their health as good. In comparison, 6.5% of a nationally representative sample of US high school students rated their health as fair or poor (Parker, 2004).

Typically, when addressing problems associated with mental illness and behavioral concerns, the first preference for parents of children with difficulties is to seek help from community sources and other family members. They are less likely than White families to seek psychiatric help initially (McMiller et al., 1996).

Empirical studies suggest that AI/AN adolescents may have more serious mental health problems than adolescents in the general population with higher rates reported specifically in the following areas: suicide, depression, conduct disorder, trauma-related symptomatology, and alcohol/substance abuse problems.  One research group found that 49% of a sample of 150 American Indian youth in a correctional facility had at least one psychiatric disorder, 13% had two disorders, and 9% had three or more disorders. When comparing these rates to those of other ethnic groups, AI/AN incarcerated youth had higher rates of disorder than non-incarcerated AI/AN youth or adolescents in general (Fox et al., 2005).

Indian gangs have emerged as one more destructive force among youth. The Justice Department views them as part of an overall juvenile crime problem on and near Indian reservations that is abetted by eroding law enforcement, a paucity of juvenile programs and a suicide rate for Indian youth that is more than three times the national average (New York Times, Dec. 15, 2009).

Elderly
Many of the elders in First Nations communities bear the trauma of forced government attempts to assimilate Native Americans into the dominant society, such as evidenced by placement of children in boarding schools, or relocations to urban centers.  Awareness of this historical trauma is needed for clinicians working with an elderly Native American population. A better understanding of the mechanisms of transmission across generations and the role of elders who experienced the boarding school catastrophe aids in the clinician’s ability to be empathic toward the client’s mental status (Whitbeck et al., 2004).

Impact of acculturation on treatment

The history of Native Americans is replete with traumatic events that impacted Native American lives. After living on the North American continent for 30,000 years as separate heterogeneous nations, Native Americans were confronted with the arrival of European settlers who invaded their ancestral lands through military intrusions, committed mass murder, engaged in massacres of tribal villages, forced persons to be removed from their territories, and broke treaties. When not engaged in warfare, forced attempts were made to acculturate the population to the colonial life and eliminate Indian culture and religion, in part by removal of children to boarding schools and foster homes. Disease epidemics spread, populations were decimated, and their culture violated. The resulting despondency and melancholy AI/ANs suffered were too often met by alcohol and drug abuse as an escape.

In recent years, there has been an increase in the use of objective self-report measures of acculturation (Holcomb, 1999), an approach that recognizes how individuals within a specific culture are likely to assign individual meaning to personal cultural experiences. Other advances are taking place in Congress, where the health care overhaul now being debated appears poised to bring the most significant improvements to the Indian health system in decades. After months of negotiations, provisions under consideration could, over time, direct streams of money to the Indian health care system and give Indians more treatment options (New York Times, Dec. 2, 2009).

The contemporary state of Native American culture is complex and diverse. While seeking to retain their tribal cultures, not all have been successful (Champagne, 1999).  A majority of AI/ANs no longer live on reservations and have blended into the American mainstream.  The degree of Native American blood lineage varies by individual.  Much intermarriage has occurred, both intertribal and inter-racial. Children of mixed marriages see themselves as only “part-Indian” and have varying degrees of identification with their Native American heritage. Given the hundreds of tribes and nations that constitute AI/ANs, there is broad variation in cultural beliefs and practices. There is no universal language use, spiritual tradition, or ritual activity.

However, all AI/AN tribes have rich cultural traditions, a literature expressed through oral story-telling (Brill, 1999), and, as in other cultural groups, unique foods, music and dance (answers.com).

[Warren Skye, Jr., LMSW, ABD; Robert Schore, LCSW; and Rachel Levenson contributed to this report.]

© 2009, OMH

The information on this page may not be reproduced or republished on another webpage or website.