Given the aforementioned lack of transportation as well as the distances between clinics and clients' homes, the first step in treatment with American Indians and Alaska Natives should be to identify where intervention should occur. In some instances, sessions will not occur or will occur inconsistently unless the clinician is willing and able to visit the client's home (Willis, Dobrec, & Bigfoot Sipes, 1992). In addition to transportation concerns, some individuals and families may be very uncomfortable visiting a clinic. For some, the bureaucracy embodied in clinics can symbolize historical and current attempts of forced assimilation. For others, concerns about confidentiality predominate.
In addition, because of the cultural emphasis on others, family or group therapy might fit better with an Indian or Native client's background and expectations than individual treatment (Sue & Sue, 1990; Trimble et al., 1996). In fact, many Indian and Native cultures have a long tradition of employing groups for social and religious activities, which have strong similarities to the techniques used in group therapy. For instance, it is rather easy to identify the parallels between "talking circles" and group therapies (Neligh, 1990). Clients might bring others with them to treatment spontaneously and the composition of who attends sessions might be fluid across treatment. Other clients, however, might feel uncomfortable discussing concerns in a group setting or request individual treatment to discuss anger or other uncomfortable affect related to disrupted interpersonal relationships. The preferences of the client should be ascertained and accommodated to the best of the therapist's ability.
Clinicians should also consider that weekly sessions lasting for 1 hour might not be an effective option for many American Indians and Alaska Natives. Given the cultural emphasis on living in the here-and-now, Indian and Native individuals and families often present with significant distress and a highly pressing issue to discuss. Not attending to these "crisis" situations at the time or soon after for lack of time or other duties (e.g., paperwork, administrative meetings) will likely seem uncaring and offensive. As further cited in Trimble et al. (1996), American Indians are more likely than other ethnic groups to underuse mental health services and/or drop out of treatment. Allowing for more lengthy sessions on an as-needed basis may be one way clinicians can make mental health services more appealing in addition to preventing premature termination. For example, if a family presents because of a recent suicide of a family member, an immediate session of several hours could be undertaken followed by a contact every day for the first week. The clinician might continue seeing all of the family or certain members on a long-term basis. Others might have gained the assistance they needed to never return to treatment.
As a final note, it is highly recommended that clinicians inform American Indians and Alaska Natives of other resources available in their communities and encourage clients to utilize these other services. Trimble and LaFromboise (1985) suggest that one reason American Indians and Alaska Natives underuse services is simply they do not know what is available. They further suggest that family and other community members can offer valuable mental health-related assistance in addition to organizations such as B.I.A. and I.H.S. Others (e.g., Manson et al., 1997; Solomon, 1992; Trimble et al., 1996) are strong proponents for using traditional methods of healing such as ceremonies, talking circles, and sweat lodges in conjunction with Western psychological treatment.
Numerous suggestions have already been outlined with regard to session content. For example, the benefits of discussing historical mistrust, cultural identity, and internalized racism have been considered to some detail. The relative predominance of affect and emotions in therapeutic sessions has also been discussed as needing to vary according to tribal or group membership. Sue and Sue (1990) also propose that describing the typical course of therapy as well as the role of the clinician and client at the beginning of treatment might prevent premature termination and increase treatment effectiveness.
Another suggestion is that clinicians working with American Indians and Alaska Natives spend as much time discussing areas of strength as areas of pathology. Clinicians are often struck with the resilience of most American Indian and Alaska Native clients in the face of tremendous hardship. Identifying such strengths is usually an easy task to achieve with this prompting. Focusing on positive experiences or capacities engenders trust in the therapeutic relationship and also facilitates the client's ability to use adaptive coping mechanisms in other problem areas. This respectful belief in and focus on the client's inherent capacity as part of the healing process is especially important given Indian's and Native's history of devaluation and discrimination.
The literature offers contradictory evidence about effective methods or approaches to counseling with American Indians and Alaska Natives. For example, Trimble and LaFromboise (1985) argue that a directive approach is the most useful stance to adopt with an Indian or Native client, whereas others argue a nondirective approach is more effective (e.g., Tanaka-Matsumi & Higginbotham, 1996; Wise & Miller, 1983). Some clinicians state that psychodynamically oriented therapy is less useful than behavioral approaches as it (dynamic therapy) emphasizes internal conflicts rather than how environmental events impact behavior (e.g., Paniagua, 1994; Tanaka-Matsumi & Higginbotham, 1996). However, interpersonal therapy, rooted in psychodynamic theory, has been seen as a promising treatment approach with American Indians (Neligh, 1990).
Given the lack of outcome studies with this population as well as the considerable diversity between and within tribes and groups, it is not surprising definitive guidance is lacking in regard to effectiveness of one treatment approach over another. Despite these controversies, however, a review of the literature supports the following propositions about therapy with Indians and Natives: (a) therapist warmth, genuineness, respect, and empathy are significantly related to successful therapeutic outcomes, and (b) therapists will need to be adaptive and flexible rather than unthinking in their application of convention counseling techniques (e.g., Neligh, 1990; Trimble et al., 1996; Trimble & LaFromboise, 1985).
The first point is generally true in treatment with all clients (Trimble et al., 1996), but considerable effort has been spent in this chapter to facilitate an empathic understanding specific to American Indians and Alaska Natives. The dangers in relying uncritically upon Western ideas about mental health and pathology also have been considered in detail. The remainder of the chapter will provide more discussion of how to adapt conventional treatment models.
From the general cross-cultural literature, Tanaka-Matsumi and Higgin-botham (1996) argue that an effective cross-cultural intervention should incorporate culture-specific definitions of deviancy, accepted norms of role behavior, and approved behavior change agents. Thus, a 16-year-old American Indian male who is brought to treatment by his parents for rebellious behavior may require treatment different from a 16-year-old White male with the same presenting issue. Unlike the White male, separation-individuation is a less important developmental task for Indians and it is socially taboo to not listen or be disrespectful of those more elderly regardless of developmental age. One's first inclination might be to teach the parents how to apply consequences when the adolescent misbehaves or to normalize the adolescent's behavior as "just part of being a teenager." It would make more sense culturally, however, to explore aspects of identity formation. If the youth identifies more strongly with and aspires the values of American Indian culture, discussing and predicting the social rejection which will inevitably result from his rebellious behavior might facilitate change. Linking this adolescent with an influential male family member, a more traditional community member, or a traditional healer might also prove effective in addition to encouraging attendance at traditional events like sweats and pow-wows.
From the American Indian literature more specifically, both Trimble (1992) and Manson and Brenneman (1995) present descriptions of how conventional cognitive-behavioral treatment programs were adapted for use with American Indian youth and elders. Manson and Brenneman (1995), for instance, adapted the Coping with Depression course created by Lewinsohn, Munoz, Youngren, and Zeiss (1986) with the aim of preventing the psychological sequelae associated with chronic disease in American Indian elders. Culturally salient examples of symptom expression and mood descriptors were incorporated into each component, and the program was expanded from 12 to 16 sessions to compensate for language and cultural barriers. The utility of this treatment and its adaptations were evident in the diminishment of depressive symptoms between pre- and posttest for those elders participating in this project. Trimble (1992) likewise modified a cognitive-behavioral skills enhancement program to prevent drug use among Indian adolescents via consultation with an Indian advisory committee, the incorporation of local Indian values, customs, and lifestyles into the intervention, and training Indian community residents in implementation of the curriculum.
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