REPORTS

Psychologists in Indian Country report

The author offers a brief snapshot of the issues facing tribal peoples, and some of the innovative services developed to ameliorate those issues

By Joseph B. Stone, PhD

Reporting to the Division 18 membership regarding Indian Country is a twofold: First, a brief snapshot of the issues facing tribal peoples and the psychologists and allied behavioral health professionals who serve the indigenous community. Second, some of the innovative and important programmatic services developed to ameliorate the above mentioned issues facing aboriginal persons, and communities and those who serve there. The alcohol dependence rate is 500 percent to 625 percent and is greater than that of all other races in this country. Comparing that rate of alcohol to the Regier et al national epidemiology studies, which reported a national alcohol dependence rate of four percent or 4 / 100, our alcohol dependence rate in tribal communities is an average of between 20 to 25 / 100 people, thusly between 1/5 and ¼ of our peoples are alcohol dependent at one point during their lives. This is reflective of a binge drinking pattern, but has enormous implications for over social functioning, since it is clear that alcohol dependent person’s behaviors have deleterious effect that spreads through their families and the social institutions and functioning of the community. In 1998, Dr. Tom Ball, a Klamath – Modoc tribal member found a post-traumatic stress rate of 78 percent in Klamath tribe using Stein’s methodology versus an 8 percent rate in the U.S. and Canadian samples from Stein’s original research. The Matasunga study of post-traumatic stress in two samples of native veterans found a post-traumatic stress disorder rate of 57 percent among Northern Plains tribal Vietnam combat veterans and 43 percent among South West tribal Vietnam combat veterans versus 22 percent for white Vietnam combat veterans. Of note, the alcohol dependence rate among these two samples of Native veterans was 78 percent. Native women experience than double the incidence and frequency of assault than any other subgroup, most occurring by non-native perpetrators. In one clinical group of Native individuals at a facility I worked at, who were being treated as inpatients for alcohol dependence, 100 percent reported a history of physical or sexual abuse. These behavioral issues represent the tip of the iceberg and clearly correlate with the full range of health disparities that U.S. Aboriginal peoples face and which is universally higher than health disparity rates reported for any other racial group in this country. Therefore, it is equally clear that appropriate interventions must be developed and implemented in Indian Country.

This is the second aspect of this brief report to the Division 18 membership. Currently, there are many new and effective methods, programs, and interventions occurring in Native communities. These represent both hope and achievement and must be highlighted. The scope to this brief report cannot elucidate the depth andbreadth of positive actions and the scope of professional commitment. Following are a few examples of where and how positive behavioral health undertakings and achievements are occurring within the Indian Health Service and tribal behavioral settings:

The Public Health Service – Indian Health Service sponsors a nationwide grant-based program wherein Indian Health Service facilities, tribes, and urban programs serving a native population are eligible to apply for funding for programs designed to ameliorate and interdict the abuse of methamphetamine and suicide. The Methamphetamine – Suicide Initiative (MSPI) program funds numerous innovative interventions nationwide:

  • Dr. Connie Hunt, a Puyallup tribal member, is the director of the Behavioral Health Program at Phoenix Indian Medical Center (PIMC), which provides community mental health and social services to any eligible American Indian/Alaska Native (AI/AN) individual or family presenting for care. PIMC serve a diverse population representing members of many different tribes, urban and rural, reservation and non-reservation, transient and long-term residents, children, adolescents, and adults. All PIMC services are provided by a team of licensed and credentialed professionals, including: Psychologists, Licensed Professional Counselors, Licensed Independent Clinical Social Workers, Licensed Substance Abuse Counselors, Psychiatrists (General, Child, & Addictions Boards), Psychiatric Nurse Practitioners (Psychiatric), and a Navajo/Cass Lake Physician Assistant who will be one of the first to sit the Physician Assistant specialty certification boards in Psychiatry.

    Since the inception of the Methamphetamine and Suicide Prevention Initiative (MSPI), this team has made tremendous progress in implementing evidence-based primary, secondary and tertiary suicide prevention strategies into daily clinical practice. The goals and objectives of the MSPI are fully integrated into the vision, core values, and daily work of each member of the department. Central to PIMC’s project is the development and implementation of a Provider Triage Model to screen for urgent and emergent concerns, determine acuity, and direct services. All new clients and those seeking walk-in services through Open Access are processed through triage. All clients presenting to triage with a positive screen (clinical or historical) for suicide related behaviors are triaged to a licensed professional for evaluation. All clients presenting to triage with a positive screen (clinical or historical) for methamphetamine are referred to a licensed substance abuse counselor for evaluation.

    The Behavioral Health program at PIMC fully utilizes the electronic health record (EHR) for records management. It is critical for quality record keeping, data mining, risk management, and billing efficiency. In the past 4 years, the Behavioral Health program at PIMC has gone from collection approximately $750,000 in billables to collecting over 2.3 million dollars in billables. Hiring strategies, exceptional providers, and clinic reorganization all play a part in increased billables; however, it is clear that EHR and template management play a key role in effective billing. Further, whatever tools PIMC Behavioral Health pilots are available to all Indian Health Service sites as well as tribal behavioral health programs.

  • Dr. Julie Yaekel-Black Elk describes Lac Courte Oreilles Behavioral Health Department prides itself in our conscientious efforts to utilize both Best Practices programming and community strength based initiatives. Staff members have been in the community ranging from 3-22yrs. Maintaining this foundation of experience in building trusting relationships in American Indian Communities is essential to progress as is the ongoing efforts to maintain staff wellness. We maintain collaborative services between Probation/Parole, Indian Child Welfare, Social Services, Vocational Rehabilitation and the Lac Courte Oreilles medical team. Financial restraints have challenged us to not duplicate services and to be aware of the importance of billing for targeted case management. Besides financial benefits, collaborative efforts also have allowed us to address AODA issues and the new challenge of prescription drug abuse while preventing those who need help from falling between the cracks.

    As a team, we direct our energies on identifying community, family and individual strengths. These identified strengths have become the structures needed to provide safe space for tribal members to take shelter to address both current and historical loss and trauma. This emotional refuge of community strengths built on a healthy staff foundation has allowed us to address effects of generations of un-parented parents due to years of child removal to boarding schools and out of home placement. Some of these effects are gangs, violence, high dropout rates, teenage pregnancies and domestic violence. Addressing these issues is not an easy feat, nor is it uncommon in American Indian Communities. What has become apparent to me over the past 22 years working in our communities is that it really does take a community to raise a child and as providers we need to support this process by nonintrusive measures that build on existing resources that will remain past the end of any specific grant funding. Activities such as the youth dance camp where the children learn traditional dance and regalia making skills from community members is an opportunity for Behavioral Health staff to share important prevention education. We have also started monthly sobriety feast which include a speaker from the community in the Winter and Spring and during the summer and fall months are complimented by community picnics and family softball games. This month we included a Halloween celebration into our sobriety feast again inviting families to participate in sober activities. Our Adolescent Day Treatment program focuses on family involvement and was previously housed in a location which reflected a home environment. Additional community based projects are diabetes prevention efforts. These include education and support groups, community gardening projects, a current research project identifying the extent of the relationship between depression and diabetes, a youth walk to school day and lastly a fitness room with equipment and training videos.

  • In Montana at the Crow Indian Health Service Hospital, Dr. Earl Sutherland, a prescribing psychologist with a specialty in Child Clinical/School psychology and Dr. Caitlyn Hall a full time pediatrician set up a child behavior clinic, because they could not obtain child psychiatry services. Their combined expertise allowed them to meet a critical need in the communities. In addition they have developed an impressive formal methodology for evaluation of child abuse and they are funded to travel throughout the various Indian Health Service agencies nationwide to provide training on their model for the evaluation of child abuse, this year.

  • In Browning, Montana, the Amskapi Pikuni Action Team (APAT), under the leadership of Dr. Paulette Running Wolf (Blackfeet), is a group of community members and traditional cultural leaders from various backgrounds and interests who participated in a community training on intergenerational trauma (sponsored via a grant via the Montana Wyoming Tribal Leaders Council (MTWY-TLC)). Together, the Montana Wyoming Tribal Leaders Council and the Blackfeet APAT team have the combined drive and interest in addressing the high levels of trauma found on the Blackfeet Indian reservation. Trauma has been evidenced through the use of annual trauma & grief screenings (courtesy of the University of Montana Native Child Trauma Center) conducted at the Browning Middle School, which has consistently over the course of several annual screenings revealed epidemic-level results. The APAT members and MTWY-TLC team are extremely interested in helping address the emotional health of youth to mitigate the effects of the trauma that these children and their families have experienced through increased access to the Blackfeet culture with the support network it offers. Because access and transmission of culture have been diminished greatly since the colonial era, the Blackfeet people feel increased self-esteem, sense of protection, mentorship, and sense of community support that students will gain through increased access to their own culture will help lessen the effects of traumatic experiences. Further by educating youth & adults the transmission of cultural values, beliefs & traditions will be improved.

    As a result of their concern, cultural leaders in the community have joined together to provide several community and school based interventions. For example, these leaders worked closely with the Browning Middle School to provide a culture based in-service for the faculty, assisting them in identifying potential student cultural leaders to assist with planning. These youth were honored at the annual Blackfeet Community College event entitled “Days of the Blackfeet” (also co-sponsored by the cultural leaders & community members to increase access to cultural values, traditions and behavioral expectations. A major theme of this event was to increase knowledge of how intergenerational trauma has impacted the Blackfeet community. Blackfeet psychologists Dr. Paulette Running Wolf, Dr. Debra Pace, and Dr. Joseph Stone gave keynote addresses on the impacts of intergenerational trauma and ways in which the Blackfeet can use their own culture as strength. Blackfeet traditional elders gave addresses on cultural healing methods and community members had a panel discussion on intergenerational traumatic and non-traumatic experiences with culture. These students were able to attend a variety of activities over four days to give them well-rounded introduction to the culture as well as an understanding of where and who they could go to for further cultural knowledge.

    The community drive evaluation of the APAT & MTWY-TLC sponsored community healing event, “the Days of the Blackfeet” revealed several key findings. The following results are highlighted:

  • 29 percent of the respondents had no idea where to go for Blackfeet cultural resources before attending Days of the Blackfeet, in contrast with only 15 percent of the respondents who knew where to go and who to see.

  • The post-test revealed that approximately 10 percent of the respondents reported having no idea where to go for cultural support. This is a decrease of 15 percent of students reporting no knowledge as compared with the pre-test results and conversely approximately 23 percent of respondents reported that as a result of attending the Days of the Blackfeet they knew where to see cultural mentorship representing an 8 percent increase.

  • Approximately 41 percent of the respondents felt that they developed some awareness of how intergenerational trauma has influenced the tribe and the culture and 70 percent of the respondents agreed that their own personal level of awareness and understanding of the impacts of intergenerational trauma had increased. After participation in the Days of the Blackfeet, 75 percent of the participants reported that their own personal sense of responsibility for transmission of the Blackfeet culture to their own family and friends had increased; while only about 5 percent disagreed with this statement.

It is evident that the APAT and TWY-TLC’s goal of increasing community knowledge on the impact of intergenerational trauma on the Blackfeet culture seems to have been met and Blackfeet APAT group work with the Browning Middle School students continues to advance as the student cultural leaders have begun to sponsor several culture-based student activities (e.g. honoring various faculty & staff in a traditional manner). Next steps for the grass root community APAT group are to continue to move forward with these types of efforts as well as to potentially establish age-graded societies in each of the schools (elementary, middle and high schools). The healing of inter-generational trauma & loss continues to gain momentum in Blackfeet Country!

Dr. David Walker, Cherokee, reported that at Washington School of Professional Psychology (Argosy University, Seattle), graduate students in his Advanced Intercultural Theories and Therapy elective have for the last two years offered a community-participatory suicide prevention project to the 14 Confederated Tribes and Bands of Yakama Nation. In 2010, students interviewed community members and surveyed research on youth suicide prevention in Indian Country toward creation of a brochure of tips and local resources at Yakama Nation. They then traveled with Dr. Walker to Yakama Nation for Treaty Days and with the support of organizers offered free brochures, buttons, bookmarks, and candy at a table throughout the first day of the celebration. This table was popular and well-received by the community. In 2011, students in this elective built upon the prior year’s success by preparing brief presentations and a community workshop under the sponsorship of Yakama Nation Tribal School and the THRIVE program. Students again traveled with Dr. Walker to the school. The morning was taken up with presentations, a free lunch was provided, and in the afternoon a community-wide talking circle was formed and blessed in order to promote consultation and action using a consensus approach. The theme of the presentations was the centrality of culture and community to effective prevention—and talks covered anything from development to equine therapy. There were over seventy participants and the circle developed several important ideas, including the launch of a local support group for survivors of suicide. Most important was the introduction of a local nonmedical inpatient resource for parents and caretakers to help youth in crisis that had been virtually invisible prior to the event. One hundred workbooks were prepared with tips and resources; there was no prior grant or funding, but THRIVE, YNTS, and Washington School of Professional Psychology school combined efforts to pick up the bill. This project was also well-received and the lead tribal administrator facilitated participation by sending a memo out permitting participants working for Yakama Nation to take the day off for the workshop.

Here, at the Gallup Indian Medical Center (GIMC), innovative efforts include the development implementation of a Traditional Medicine Department housing a Navajo (Dine) Hogan and Sweat Lodges for ceremonies. Two Dine Medicine men provide traditional spiritual diagnosis and treatment and act as consultants and trainers for not only this hospital but numerous other facilities. Despite their incredible range of traditional knowledge, both of these traditional practitioners hold advanced degrees from Western Universities, and one, Mr. Eric Willie (Dine) has published in peer-reviewed journals and has completed a formal clinical internship in counseling with me. He is poised to become a Licensed Professional Counselor in New Mexico. This blend of traditional with modern methods extends to a very positive and supportive collaborative relationship between the GIMC Behavioral Health Services and the GIMC Traditional Medicine Program and we often share clients and work together for good of the people and communities. The GIMC MSPI project empathize the provision of Navajo (Dine) culture and cultural training to community children and families as a preventative mechanism for methamphetamine and suicide through the development of a positive Indian Identity. The GIMC acting clinical director, Dr. Paula R. Mora (Dine) has stood behind and worked collaboratively with BHS staff on many projects. Recently Dr. Mora and the GIMC BHS supervisory social worker, Mrs. Bettie Begay (Dine) developed a professional social worker into primary care pilot project. This project involves placing licensed social workers into primary care clinics hospital-wide. Our partnership (as psychologists) with the social workers in this pilot program illustrates the beneficial outcomes of collaborative relationships in program innovation.

I was pleased to make this report to Division 18 membership. As noted above, the challenges in Indian Country for the people and the professionals staffs, including psychologists, is robust. I regard these challenges, described statistically in this report’s introduction, as residual effects of the long history of Historical Trauma and Post-Colonial effects imposed on the Indigenous people by a clash of cultures. However, clearly, in Indian Country the programmatic response to these challenges secondary to Historical Trauma described here are innovative, hopeful, and effective. I am particularly gratified to make note that when psychologists and other behavioral professionals make note of and incorporate interventions within a framework based on the positive cultural and spiritual strengths of the Aboriginal community, the outcomes are inevitably better for the people. Understanding this concept of embedding the best of western science into a system defined by Native thinking, values, beliefs, and practices and incorporating it in our practices as psychologists who serve tribal peoples and communities is necessary for the best outcomes to occur.