Cultural values effect the assessment and treatment process in terms of clinical judgments about normalcy. Erroneous judgments can lead to misunderstanding, overpathologization, or implementation of a treatment plan that is not culturally consistent. In addition, clinicians who lack understanding of these differences might unknowingly act in a manner that jeopardizes rapport and trust.
Misunderstandings within the therapeutic relationship not only occur because of the language-related issues covered earlier, but result as well from differences in the experience and expression of affect. As indicated, Indians and Natives are less likely to separate aspects of themselves such as their physical, mental, and social selves (Richardson, 1981). Typically, affect is more contextual and related to interpersonal difficulties rather than the "ego-oriented, context-less self-statements of dysphoria (e.g., I feel blue) or worry (e.g., I fear things)" (p. 490) present in more egocentric cultures (Manson, 1995). Discussing difficulties in determining the presence of depressed affect among American Indian Vietnam Veterans, Norton (1997) wrote, "It is as if the interviewer and veteran are having two separate conversations, the interviewer is asking about an interior life of emotions, and the veteran is telling her about an outer life of social relationships" (p. 26). Thus, if a clinician asks an Indian or Native client to identify and label his or her feelings, this probing might produce confusion or a paucity of information. It might be more helpful for the clinician to first inquire how things have been socially for the client and then ask how any difficulties noted have affected him or her in a feeling or emotional way. Indian or Native clients are also more likely to express affective concerns in somatic terms given the lack of differentiation between somatic and other aspects of one's being (Manson, 1995). Clinicians might gain insight into the emotional states of Indian or Native clientele, therefore, by attending to changes in physical well-being.
Moving to typical situations open to overpathologization, numerous authors warn against labeling commonly occurring hallucinations or delusions as signs of schizophrenia or other serious psychopathology (Manson et al., 1985; O'Nell, 1989; Pollack & Shore, 1980). It might not be at all unusual for Indians or Natives to "see" or "hear" a recently deceased person or, in some tribes, to believe one has been inhabited or cursed by a witch. Manson et al. (1985), for example, found 20% of a group of clinically depressed Hopi individuals experienced these types of hallucinations without significant social or cognitive impairment.
Indians and Natives can also present with a subdued manner and lack of eye contact that seems "withdrawn," "passive," or indicative of "flat affect" to the inexperienced clinician. Downcast eyes and a composed demeanor are cultural expressions of interpersonal respect within many tribes and groups. O'Nell (1989), in fact, postulates in her review of the literature the "flat affect" displayed by many Indians and Natives is often mislabeled as a symptom of schizophrenia rather than a cultural difference in the display of emotion. She warns of the dangers inherent in committing "category fallacy" or the application of Western categories of illness to a non-Western culture. She writes clinicians cannot validly "rule out the possibility that the converse of these manifestations, i.e. 'emotional lability,' 'inability to contact the spirit world,'. .. indicate a great degree of pathology . .. than the original 'signs'" (p. 78) of flat affect or delusions.
The application of Western ideas about separation-individuation, child rearing, achievement, and problem solving can also be problematic as depicted in the following scenarios. First, Indians or Natives often live with their nuclear or extended family throughout most of their lives (Staples & Mirande, 1980). A 35-year-old Ute male who lives with his family in his parents' home is thus not necessarily "dependent," "insufficiently individuated," or otherwise pathological. He is also not "passive" or "too focused on what others think" if he makes decisions based on the preferences of his wife and grandparents or "conflict-avoidant" if unwilling to share angry feelings with his family. Labeling him as "codependent" and encouraging him to "set boundaries" with his family might cause considerable psychological distress as well as rejection from members of his culture. Given more fatalistic beliefs, it is not uncommon for Indians, especially more traditional ones, to cope with stress such as anger towards family by waiting for a solution to appear (Trimble et al., 1996) rather than being "proactive" and planning how to cope differently in the future. Clinically, Indian or Native clients might be prone to missing appointments, especially if their presenting concerns have improved. This is not sufficient evidence to deem the client irresponsible or "crisis-oriented," a term with highly negative connotations among treatment providers. The here-and-now emphasis of the culture as well as the multitude of stressors present in many Indian and Native lives might lead the client to quite reasonably decide something else is more of a priority than an appointment.
Second, given the different philosophies about learning, a Native husband and wife should not be automatically considered "permissive" parents in need of a strict behavioral plan if they rarely discipline their children. Culturally, this couple is also not considered neglectful if the children's grandparents take as much responsibility in child rearing. Lastly, a 10-year-old Ojibwe boy who is reluctant to participate in competitive activities at school isn't necessarily unable to complete the task or suffering from low self-esteem. In his family and tribal life, it might be highly offensive to try to look better than others.
On the clinician's part, interrupting a client who digresses from something seemingly more important could be highly offensive as could actively confronting the client. A clinician who spends considerable time talking about their credentials or their thoughts or beliefs might also be seen as a "know-it-all" or rude because of lack of humility.
The previous paragraph concludes the discussion of more contextual and global factors related to therapeutic work with American Indians and Alaska Natives. These factors were presented to facilitate the development of empathy, respect, and understanding on the part of clinicians, especially those unfamiliar with the Indian or Native population. Without these qualities, a strong therapeutic alliance is unlikely to ensue between the Indian/Native client and clinician, and even the best assessment and treatment approaches will likely fail. With this backdrop in place, the chapter now shifts to specific assessment and treatment suggestions to help clinicians more successfully enact their role as diagnosticians and treatment providers.
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