Ideas of culture in an urban American Indian behavioral health clinic

A dissertation summary from the 2017 Distinguished Dissertations in Qualitative Inquiry Award winner.

By William E. Hartmann

This dissertation used clinical ethnography to explore relations between clinical practice and culture concepts in an urban American Indian behavioral health clinic (Hartmann, 2016).

Culture concepts in American Indian behavioral health

The concept of “culture” maintains an extended history of being taken up by diverse groups and ascribed different meanings to serve distinct agendas (Williams, 1976). American Indians (AIs), for example, were first introduced to an idea of culture in the context of Euro-American theories of cultural evolution, which functioned as rationale for extermination, land dispossession and forced assimilation. The past half century, however, witnessed concepts of culture shift from something AIs lacked (as “savages”) to the centerpiece of national movements for AI empowerment, a la “cultural revitalization.” Meanings of culture concepts are thus inseparable from the sociopolitical agendas they advance, and in the wake of a violent colonial project to displace and erase indigenous peoples from North America, discussions of AI culture(s) are inextricably tied to concerns about the distress and well-being of AIs (Gone, 2006).

This confluence of clinical and sociopolitical concerns around AI culture, distress and well-being is particularly salient in contexts of providing behavioral health (BH) services to treat debilitating distress among AIs. Although an afterthought in most BH settings (e.g., Quintero, Lilliott & Willing, 2007), culture and its role in supporting individual and community wellness is a major concern for community BH clinics funded by the Indian Health Service (IHS) to meet the BH needs of AI communities. Yet, despite over 60 years of IHS operation, little is known about how these therapists think about culture and how those ideas shape BH services. 

A brief clinical ethnography of culture concepts in the clinic

To better understand relations between clinical practice and culture concepts, I partnered with an IHS-funded BH clinic in the Midwest to collaboratively develop an ethnographic project guided by the following research questions:

  • How do therapists in this BH clinic conceptualize culture?
  • How do culture concepts shape BH services?
  • How do the relations between culture concepts and BH services speak to the larger socio-political interests of AI peoples (e.g., nationhood, sovereignty)?

These questions helped maintain a dual focus on clinical and sociopolitical functions of different culture concepts operating in the clinic and attending to therapist reasoning and tacit assumptions that informed BH service provision. The resultant project was organized as a brief clinical ethnography involving 19 weeks (approximately 608 hours) of intensive participant observation in all clinic settings except client encounters, interviews (58 semi-structured, 57 impromptu), and collection of clinic materials (e.g., handouts, online representations of the BH clinic). Data were primarily collected from 12 BH service providers (five employed therapists, six student interns and one cultural aide), however, administrators and several staff were also interviewed.

Data analysis began with professional transcription and an inductive thematic analysis (Braun & Clarke, 2006) of a semi-structured interview with the five therapists about culture in the clinic. Three overarching themes were identified (cultural disconnect; cultural reconnect; Native essence) with four sub-themes (colonial violence and identity distress; cause and consequence for cultural disconnect; new perspectives and spiritual wellness; goals of cultural reconnect), each endorsed by all five therapists. I then turned to the larger data corpus to clarify and contextualize interview findings by drawing out patterns in clinic materials and field notes that documented concrete, detailed day-to-day descriptions and demonstrations of clinical practice (e.g., What do you plan to do in this session? How would you do that?). Both analysis — interview and ethnographic — entailed an iterative evidence-checking process with two dissertation committee members, and post-project feedback from therapists was affirming of findings. 

Results

Interview analysis results indicated that therapists understood themselves to be engaged in a sociopolitical project organized around alleviating identity distress among urban AIs by reconnecting them to the culture of AI ancestors through engagement with traditional cultural forms in therapy (e.g., traditional AI ideas of wellness represented in the Medicine Wheel). These ideas were presented within a meta-narrative locating cause of AI suffering in cultural disconnect and prescribing healing via cultural reconnect. Embedded in this meta-narrative was an idea of Native essence, which tied cultural reconnection to pre-colonial AI lifeways.

However, ethnographic findings clarified that the cultural dis/re-connect meta-narrative functioned primarily to repackage familiar, high quality clinical practices as distinctly Native. Instead of cultural reconnection, decontextualized and romanticized representations of AI culture were added to standard clinical practices to make BH services more appealing to urban AIs and assist clients in developing positive modern Native identities that might buttress against messages of devaluation encountered in modern America (i.e., cultural reimagination).

Findings and implications

Findings highlighted a disjunction between how therapists thought and talked about culture and clinical practice in abstract (cultural reconnection) and how they described and demonstrated clinical practice in concrete (cultural reimagination). This disjunction reflects a major predicament facing the fields of BH wherein engagement with diverse cultural traditions stands at odds with many modern American cultural assumptions embedded in clinical training (e.g., American individualism). Encouraged to engage traditional AI cultural forms, therapists in this clinic — like counterparts across fields of BH — did not abandon modern clinical training. Instead, they repackaged clinically familiar ideas, tools and techniques by adding symbols of indigeneity to otherwise standard, high quality clinical practices. On one hand, this repackaging of BH services could be therapeutic for urban AI clients, however on the other, it raised concerns about reifying limited representations of AI culture that fit into the clinic setting and further marginalizing more substantive cultural differences (e.g., psychological-mindedness, see Hartmann & Gone, 2016). For fields of BH, then, a productive engagement with culture concepts will require greater familiarity with ethnographic interviewing techniques in clinical settings (e.g., Kleinman & Benson, 2006; Saint Arnault & Shimabukro, 2012) and a broader return to contextualism in BH research to relocate inquiry outside the clinic and into diverse community settings to de-center and de-naturalize established knowledge, practices, and institutions through empirical representations of local experiences in these contexts.

Furthermore, in the present context of increasingly reductionist inquiry in clinical science and BH (Gone & Kirmayer, 2010), this work challenges predominant narratives to assert that it is this kind of exploratory, qualitative and highly contextual inquiry that constitutes “rigorous science.” Had I simply taken research participants’ reasoning about culture for culture itself, which is the most common approach to culture research in BH and psychology (e.g., analyzing survey or interview responses from members of a “cultural group”), I would have been left with the misleading impression that therapists were engaged in a radical sociopolitical project of reconnecting urban AI clients to the life worlds familiar to AI ancestors. However, through this highly contextual and exploratory form of prolonged inquiry it was found this meta-narrative did not explain clinical practice. Instead, by triangulating interview data with clinic materials and therapists’ concrete descriptions and demonstrations of clinical practice (via role play), it became clear therapists were using symbols of AI culture to repackage common clinical practices as culturally different in support of therapeutic identity work. Thus, clinical ethnography and other ethnographically-informed qualitative methods will be needed to reach beyond what is readily articulated by therapists (or clients) to develop a more rigorous science of psychology and clinical practice that can render more accurate and compelling accounts of culture and human diversity.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. http://doi.org/10.1191/1478088706qp063oa.

Gone, J.P. (2006). Mental health, wellness, and the quest for an authentic American Indian identity. In Witko, T.M. (Ed.). Mental health care for urban Indians: Clinical insights from Native practitioners. Washington, D.C.: American Psychological Association.

Gone, J.P., & Kirmayer, L.J. (2010). On the wisdom of considering culture and context in psychopathology. In T. Millon, R.F. Kruger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations of the DSM-V and ICD-11 (pp. 72-96). New York: Guilford Press.

Hartmann, W. (2016). Ideas of Culture in an Urban American Indian Behavioral Health Clinic (Doctoral Dissertation, Department of Psychology, University of Michigan).

Hartmann, W.E., & Gone, J.P. (2016). Psychological-mindedness & American Indian historical trauma: Interviews with service providers from a Great Plains reservation. American Journal of Community Psychology.

Kleinman, A. & Benson, P. (2006). Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine, 3, 1673-1676. 

Quintero, G.A., Lilliott, E., & Willging, C. (2007). Substance abuse treatment provider views of “culture”: implications for behavioral health care in rural settings. Qualitative Health Research, 17, 1256–1267.

Saint Arnault, D. & Shimabukuro, S. (2012). The clinical ethnographic interview: A user-friendly guide to the cultural formulation of distress and help seeking. Transcultural Psychiatry, 49, 302–322. http://doi.org/10.1177/1363461511425877.

Williams, R. (1976). Keywords: A vocabulary of culture and society. London, U.K.: Fontana.