Of the demographic factors discussed, perhaps the one with the greatest influence on assessment and treatment is the tremendous diversity in tribal or group affiliation. As so eloquently said by Mary Ann Broken Nose (1992):
In truth, the Indian nations of North America are as different from one another as are the countries of Europe. .. . Barring the intervening influence of the dominant Anglo-American culture, a Seminole has as much in common with a Sioux as does a Sicilian with a Swede. Each tribe has its own language, religious beliefs, traditions, and way of life (p. 380)
Thus, it is very difficult to make generalizations about Indians or Alaska Natives for clinicians to use in the assessment and treatment process. It is essential clinicians take the initiative to learn about the unique aspects of their client's tribe or Native group for several reasons. First, this information can assist in more accurately assessing the presence or absence of pathology. Cultural information offers the clinician a normative context in which to evaluate the client and determine if the client is thinking, acting, or feeling in an expected fashion. Second, this knowledge can prevent the clinician from offending the client and unnecessarily jeopardizing rapport as well as helping the clinician choose a culturally compatible therapeutic approach.
As an example of how clients with different tribal or group affiliations can vary, several American Indian tribes, including the Navajo, have strong taboos against speaking of individuals who are dead or the manner in which death occurred. In contrast, the Oglala Sioux, although reticent to talk about death, do not have the same strong prohibitions. A clinician working with an Oglala Sioux tribal member whose relative has been murdered might be able to do in-depth grief work of a cathartic manner once sufficient trust has developed. However, a clinician working with a Navajo tribal member who has suffered loss would be wise to refrain from talking about the specifics of the murder regardless of the level of trust.
To offer a brief (but important) caveat, despite the utility of learning about a client's culture, clincians must always remember that groups and tribes vary tremendously according to factors such as degree of identification with Western ways, education, and even personality. As with any client, an Indian or Native needs to be seen and understood as unique.
Secondary to tribal or group affiliation, assessment and treatment can be significantly affected by language. Language barriers can impede the process whether the client is monolingual (necessitating the use of a translator) or mostly bilingual. Bilingual clinicians or professional translators are rarely available, and family, friends, or community members frequently are the only option. Significant others as translators can increase the client's comfort in discussing distressing topics. The former may also offer clinicians useful information about the client but there are potential downfalls. Besides the obvious limits to confidentiality, family or friends can minimize or exaggerate client's symptoms or avoid uncomfortable topics such as suicidality (Westermeyer, 1987). In addition, certain emotional states are very difficult or even impossible to translate. For example, words for "depressed" and "anxious" are absent from certain Indian and Native groups (Manson, Shore, & Bloom, 1985). In sum, translators may not be able to accurately solicit or convey information (e.g., the presence of depressed affect) or can present the client in distorted manner.
Even for the bilingual client, communication problems may continue to be present. For example, McNabb (1990) documented difficulties in achieving semantic equivalence for common self-report terms such as "somewhat satisfied" across four Alaska Native groups. When "somewhat satisfied" was translated into Central Yup'ik, the resulting phrase meant "approve of it partly" while translated into Siberian Yup'ik it meant "insufficiently satisfied." Thus, a bilingual Yup'ik male who endorses he is "somewhat satisfied" with his marriage on a questionnaire might not need to discuss his relationship. But it is equally possible he is rather unhappy with his marriage and that relationship issues should be a predominant treatment theme.
It is further important to remember emotional states such as anxiety and thought problems will affect a client's communication in a second language more dramatically than the first, as facility with a second language is more tenuous. A Sioux male who learned English second might look highly disturbed and in need of hospitalization to an English-speaking clinician. If this same client were able to speak with a clinician familiar with his first language, however, it might become evident the client is highly stressed but not in need of emergent intervention. Suzuki and Kugler (1995) also warn that the dysfluen-cies common when acquiring a new language can look like symptoms of a language disorder such as dyslexia.
In addition to considering group differences and the effect of language, the clinician should use demographic and socioeconomic factors as additional pieces of data when assessing for health and pathology. For example, it is common for Indian or Native females to have children at a young age and, within some tribes and groups, this behavior is encouraged. A seventeen-year-old Indian female with two children has not necessarily experienced family or peer disapproval, stress related to dropping out of high school, or be considered irresponsible. In a similar vein, because of higher unemployment rates, a jobless Inupiaq male should not automatically be considered as meeting the Antisocial Personality Disorder criterion C(l) ("inability to sustain consistent work behavior"). The availability of jobs in his village and the norms in his community regarding employment should be explored first. Subsistence remains the primary way many Inupiaq Eskimos provide for themselves with seasonal employment undertaken only to obtain enough money to maintain equipment.
On a more practical level, demographic and socioeconomic factors can create logistical barriers to treatment, especially when implemented in the traditional manner with the client attending a session at the clinician's office. First, the considerable distances that frequently exist between clients' homes and clinics make access to treatment difficult, as many reservation Indians do not own cars. In Alaska, many Natives live in villages accessible only via airplane. Even contacting a client to set up appointments can be challenging given the lack of telephones. If treatment is available on reservations or in villages, many Indians and Natives then worry about confidentiality and the stigma that can occur in seeking out mental health treatment. The size of most communities makes clinicians very visible and their clientele perhaps even more visible. For rural Native Americans who live far from IHS facilities or who choose to seek treatment elsewhere, the standard fees of private clinicians may simply be impossible given limited financial resources.
For the urban Indian or Native, many of the barriers present for their rural counterparts also exist (e.g., lack of transportation, inadequate finances). Urban Indians and Natives also may have difficulty in developing a sense of community, which might serve to protect them against developing psychological or physical problems.
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