 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on improving cultural competence, working with Native Americans and Alaskan natives. In this presentation we're going to explore questions to consider when developing the case formulation and treatment plan, and we're going to examine demographics, the prevalence of problems, health disparities, historical contributors to problems, specific Native American values, communication guidelines, worldview differences, differences in approaches and treatment, perspectives on health and healing, culture-bound symptoms, and approaches which may be helpful with this population. So strap in, we're going to go fast. So the first, you know, 8-10 slides are just giving you some background information. There are 566 federally recognized American Indian tribes, and their members speak more than 150 different languages. Numerous other tribes recognized only by states and still others that go unrecognized by government agencies of any sort also exist. So, you know, if you're dealing with these other tribes that may not be federally recognized or even officially recognized, we want to look at how that impacts culture and how that impacts people's ability to access treatment. Native Americans who belong to federally recognized tribes and communities are members of a sovereign Indian nation that exists within the United States. On lands belonging to these tribes and communities, Native Americans are able to govern themselves. So there's, you know, different rules and regulations there. Healthcare is provided to many Native Americans on reservations by the Indian Health Services, but they are on the reservations. So that's actually only about 20% of the people of the Native Americans or American Indians that could receive services. Native Americans, by virtue of their membership in sovereign tribal entities, have rights that are different from those of other Americans. So if you're working with Native Americans, especially if you're working on a reservation, you want to make sure that you know any special rights that those persons may have. 28.3% of American Indians and Alaskan Natives report having mental illness. That is a big number. That's almost a third, more than a fourth. And approximately 8.5% indicating serious mental illness in the past year. So again, that's almost one in 10. That's a pretty big number. Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial or ethnic populations. And more than 10% reported a major depressive disorder in the past year. Ouch. So I'm just kind of giving you an idea when you think about how many Native Americans or Alaskan Natives or American Indians are in your area. How many of them you see in your practice versus how many of them are actually struggling with problems. Common disorders in this population include depression, anxiety, and substance abuse. PTSD rates are taken from the AAI Super PFP study. And the links there, you can go look at it. It was a study done to identify prevalence for American Indians. Shows that 12.8% of Southwest Tribal samples met criteria for a lifetime diagnosis of PTSD compared to 4.3% in the population. So triple. Wow. Okay. So higher incidence of PTSD. So you might be going, well, why? Well, there's a lot of historical reasons and we can get into that. But there are also other reasons. American Indians and Alaskan Natives have the highest, second highest infant mortality rate in the nation and the highest rate of sudden infant death syndrome. So you've got a lot of trauma here in a lot of families with this, with higher rates of infant mortality and sudden infant death. Native Americans and American Indians are less likely than other Americans to graduate high school or complete a college degree. Now it's important to recognize that American Indian students achieve on par with or beyond the performance of non-Indian students in elementary school. So they are doing fine. They're just trucking along. And then all of a sudden they hit middle school and it comes to a screeching halt. And they start to show a decline in performance between fourth and seventh grades. These children may have culturally rooted ways of learning, which are at odds with teaching methods currently used in public education because they typically are visual learners. And a lot of what we do in public education and private education is lecture. So working with these students to help them figure out, okay, how can I make this learning environment work with for me? And working with the schools to advocate for them can be really helpful in hopefully preventing some of this decline. Because when we see this academic decline, we also see a corresponding decline in mental health. So as their grades start to fail, self-esteem may take a toll. You know, there are a lot of different factors that could be going on here, you know, developmentally, culturally and academically. But we see their mental health status start to decline. So we need to start looking at early intervention and prevention services. The poverty rate for America as a whole is 14.3 percent, you know, depending on what statistics you use. For Native Americans, it's about 26 percent. Again, about double what you see in the rate general population. Native Americans have the lowest employment rate of any racial or ethnic group in the United States. In the poorest Native countries, only about one third of the men in Native American communities have full-time year-round employment. So that's a lot of poverty that we're dealing with. And we know the stresses that poverty causes. We know poverty is a risk factor for a whole bunch of stuff for obvious reasons. So on our part, you know, we can do some advocacy interventions. We can also, you know, do some early intervention to help people with stress management and maybe some life skills to help with budgeting and, you know, help them figure out how to reduce the stress that's caused by the poverty. Historical contributors to mental health and substance abuse problems. Historical reasons for the development of binge drinking specifically among Native Americans has been the existence of dry reservations, which can limit the times when individuals are able to get alcohol. High levels of poverty, we know it's a risk factor. Lack of availability. So in remote Alaskan villages, for example, they may not be able to access alcohol very often. So then when it does come, it tends to be more of a binge drinking scenario. A history of trauma and loss of cultural traditions have all been statistically linked or correlated with the development of mental health or substance abuse issues. Issues impacting parenting and prevention that can lead to increased neglect and abuse are also present. Back, you know, in the day, if you will, which that day wasn't so long ago, a lot of Native American children were removed from their families and sent to boarding schools. And due to this separation from their families, when these children became parents themselves, they weren't able to draw on any experiences of growing up in a family to guide their own parenting. They don't know what mom and dad are supposed to be like or what their roles are supposed to be. Poverty and demoralization can also contribute to high stress in a family and leading to lead to increased neglect and abuse. Rapid cultural change is also an issue. So we want to look at what's happening, what's causing this stress, what's causing this family, family instability and the negative mental health impacts that come with it. Six in 10 American Indian and Alaskan Native families were headed by married couples and eight in 10 of the nation's other families were. So they even have a higher level of single parent families, which can contribute to stress and poverty and a variety of other things. Health disparities, you know, if you're not physically healthy, it's harder to be happy and, you know, function at work as well. You're going to have more sick days and things like that potentially. So what are some health disparities? Heart disease, cancer, unintentional injuries, diabetes, depression, anxiety, PTSD and suicide, obesity, substance use, sudden infant death syndrome, teenage pregnancy, liver disease and hepatitis. Remember, there's a high 60% higher infant mortality rate for Native Americans than for Caucasians. And they also have a almost a little bit more than double almost triple the rate of tuberculosis than Caucasians do. So there's a lot of health stuff going on here. Early intervention with health practices, education can also help with some of these things. You're not going to be tested on the health disparities. I just think it's important to understand that it's not just mental health. It's physical health. It's financial stability. A lot of different things can negatively impact this population. Diabetes is increasing among Native Americans and approximately 38% of elder Native Americans have diabetes. Just let that sink in for a second. That's more than one in three. Diabetes is also associated with both substance use disorders and depression. So if we know that diabetes is associated with depression, then we need to try to intervene and do early intervention for both of them or prevention, ideally. In some Native American communities, inhalants have been a major drug of abuse for adults as well as youth. For example, early in the 1990s, about 46% of the adult population on one reservation were thought to abuse inhalants. So there's definitely some culture at work here in terms of a drug using culture or approving of the use of certain drugs in some instances. Native Americans are about 1.4 times more likely than white Americans to have a lifetime diagnosis of an alcohol use disorder. An illicit drug use is also more common for Native Americans than for members of other major racial or ethnic groups. So that's kind of your demographics that gives you an idea about what might be underlying some of the stuff that we're going to talk about. Specific Native American values that we need to consider in tailoring our approaches. Native Americans generally value the community's best interest over their own individual interests. So there are collectivistic society and every culture that we're talking about this week, they're all collectivistic. And typical American society is individualistic. So it's important that we look at how we're approaching things and how that person's view of things may impact what they choose for treatment and what they see as worthwhile goals. When an individual is experiencing problems, it interferes with his or her ability to fulfill his or her role in the community. So it's not, I don't feel well. I can't do what I want to do. I don't feel well. I am letting down my family. I am letting down my community. Many believe that addiction or mental health problems hurt and weaken the entire community. So it's important that the community ensures that every other person is doing well. This collectivistic role can increase motivation for change by inspiring clients to change for the good of the tribe and for the good of the next seven generations to come, even if they don't want to change for themselves. And there is a document in your class that is a text, it's 80, 100 pages, something like that, on motivational interviewing and it was specifically adapted to be used with the Native American population. So that provides you some interesting tools and tips. A lot of it is very similar to straight up motivational interviewing, but it does give you some tips that we'll talk about a little bit here on how to make it more culturally responsive. World view differences in mental health treatment. So you have relational approaches or relational philosophy in the American Indian and Alaskan Native populations. That's what AIAN stands for. In the majority culture, we tend to go from point A to point B. And even when I talk about recovery and goal setting and treatment planning, a lot of times I use that very phrase. You know, you're here and how do you want to get from point A to point B? But when you're working with this culture, you have the people who want to get from point A to point B, but they need to consider how it's going to affect everybody else along the way and factor all that in because everything is in relationship. Every change is in relationship to how it impacts the other things and people that are important in their life. And that's a major consideration. In the Native American culture, mind, body and spirit are one. You don't have mental health disorders over here and physical health disorders over here and spiritual back here. You have one person that is fully integrated. So we need to figure out, you know, when we're working with this population, how do we tailor our approaches? And we can't just, well, we probably shouldn't just focus on one thing, just the psyche. We need to embrace the totality of the person. Now, we may not be skilled to address the spiritual and the body aspects. No doubt that's out of our bounds of competence. But we can refer out and we do need to incorporate those important people and pieces into the treatment plan. American Indians tend to go with an idea of mysticism and acceptance. You know, this can, whatever is afflicting me can be caused by a variety of things and I need to accept that it's going on. And we'll talk later. There's term fatalistic attitude and I don't like that word because it sounds negative, but they're accepting. It is what it is, sort of radical acceptance. Whereas in the major culture, we want to do scientific studies. We want to have verification that this causes that before we'll believe it. So there's more of a culture of acceptance here. They have ceremonies and rituals, which they use for cleansing, balancing, healing. We tend to focus on treating mental health with psychotherapy. So again, that's just focusing on the psyche as opposed to focusing on the entire person. Tribal connectedness is valued and encouraged in mental health treatment. Whereas in the majority culture, we focus on the individual. In American Indian culture, there's a focus on spirituality and balance and cooperation and sharing of resources of what's going on. And even the way they approach mental health care, and we'll talk about that in a little while, has an attitude or an essence of cooperation and sharing, patience and respect, a present orientation and healing through herbs, plants and nature. So it's important to look at the differences here. Now the majority culture, on the other hand, we tend to have organized religion in terms of addressing spirituality. We may refer out and go see your priest or your pastor or your spiritual leader, but we tend to not integrate it as much and there's not as much balance. It tends to be disconnected parts of a whole instead of interconnected parts. We tend to favor and prize in the majority culture competition and winning and assertiveness and forcefulness, and that's not prized in the American Indian culture, necessarily. And we tend to have a future orientation. What do you want things to be like five years from now, as opposed to what would help make you happy and feel good in your skin right now? What's the present? What do we need to focus on? And we tend to look towards psychopharmacology and drugs where instead of going first to herbs, plants and nature. So there's just different approaches. It doesn't mean our way is wrong. It just means they will have a different approach and we need to respect that. So if they want to go to their tribal healer or a tribal elder or whatever as part of their treatment, great. Let's figure out how to integrate that into the plan. Communication guidelines. With this culture, you should really know someone well before speaking to them for long periods of time or confiding in them. So you don't just meet them the first day and start spilling your guts. And this is what we typically expect in an assessment. It's like, hi, how you doing? I'm Dr. So-and-So. Sit down for the next hour and a half. You're going to tell me all the dark, nitty-gritty details of your life. That is not culturally sensitive. It's not sensitive period, but it's definitely not culturally sensitive. So we need to look at that in terms of making our assessment process a little bit more culturally responsive. What can we do in order to make this feel a little less vulnerable or whatever word you want to use? Children should not display themselves verbally in front of adults. So you're not going to see as much acting out. And if you're dealing with families, this could be an issue that comes up where a child speaks out, talks out, asserts his or her own opinion about something and is chastised for it. So we need to understand what the children's place is in terms of what this culture views as appropriate behavior for children. It's inappropriate to express emotions in public or around people you don't know very well, either verbally or non-verbally. So again, we meet somebody. We've known them for all of 30 minutes. We're asking them about some really painful stuff, yet it's not appropriate to express emotions around people you don't know very well. And so people feel very vulnerable, very exposed. And when they're in your office, even though it's technically private, it's also still technically public because they don't know you from Adam's house cat. And they're not in their house, in their room, in their sanctuary. You want to try to avoid asking direct questions and expecting an immediate response from people you don't know very well. So if we're asking, which again is the assessment, we want to go gently. If somebody pauses, it doesn't mean they're being resistant or avoidant. They're thinking of how to say it, how much they want to share. That's okay. It's inappropriate to verbally discipline or praise a child in public. So if we don't see a lot of this when we're observing parent-child interactions, if we don't see a lot of this, it doesn't mean it doesn't happen. It means it's not culturally appropriate to do it in public. And if we're observing or probably in public of some sort. And this is also probably true in the school systems in which the child is enrolled. And it's inappropriate to speak for someone else. No matter who that person is, everybody's entitled to their own opinion, even a child. And that's an important thing. So up here it says children should not display themselves verbally in front of adults. Don't throw a temper tantrum. You know, don't yell, don't scream, don't be oppositional. You have a right to your own opinion and there's a time and a place for it. So helping children figure out how to navigate that boundary. In Indian conversations, it's not the person who speaks first who necessarily controls the topic. This is because an immediate response to what has been said may be delayed. The respondent therefore has control over the topic by choosing when to speak and what to say. So when we're in counseling and, you know, we ask somebody a question and they think about it and they ponder it and then they say whatever they want to say. But then we have a chance to ponder and say something else that's, we're not handing over the power to them, so to speak. Don't call somebody out directly, you know, try to hedge it, try to be a little bit more tactful. Try not to compete with answers somebody gives because no answer can be said it is wrong from a certain point of view. Every answer may be right. So we may want to point out our point of view, but we also want to validate and this is very dialectical in nature and do not look directly at somebody the entire time they're talking. So most of the time, especially if you're not a new counselor, you probably don't do this anyway, but you don't want to stare at somebody the whole time, even if you think it's showing that you're super attentive. You, you want to look down you want to look away occasionally so they don't feel like they're on the spot and they're completely revealed. Be careful and bringing up the topic of spirituality though and spirituality is very central to Native American values, but they are sacred and secret traditional practices. And the spiritual leaders may have the role of providing guidance for so it may not be our place to go there. We may want to learn about their spiritual practices and their culture, and we can ask about that but it's not our place to usurp the guidance and healing practices of the spiritual leader. Many Native communities have long histories of contact with missionaries and may have adopted, rejected or blended Christian beliefs with their own native beliefs. So we need to understand where they're coming from. And we can't just assume. In general, there is a belief in the creator, the grandfather, God, God's or a higher power in their religion somewhere. So there's a unifying concept. For some Native American spirituality is an integral part of who they are and the world around them. And it's important to remember when they seek out Native healers, the Native healers don't separate mind, body and spirit but see them all as connected. We're going to talk about that multiple times. So the Native healer becomes an important part of the multidisciplinary treatment team if you're seeing someone who is Native American, because the Native healer is also working on some of those issues and you can work together collaboratively and do really powerful stuff. Or you can step on each other's toes and it's not helpful. When it comes to addiction and I did put this in here because I think it's interesting to point out. Some believe that addiction is a spiritual entity that has its own voice. The spirit of addiction tries to seduce or tempt the person to drink or use other substances. And sometimes it's the only way people know how to cope with their own problems. And you can read more about that in the book Native American post-colonial psychology. The Native American recovery movements often viewed addictions as the result of cultural conflict between Native and Western cultures and saw the Western cultures using substances as weapons to cause them future loss and to remain oppressed. To best treat this population, we have to embrace a broader view that explores the spiritual, cultural and social ramifications of the substance use. We need to talk about how current behaviors interfere with the Native American spirituality in order to help them increase their motivation and make positive changes. I said we'd get to this differences in mental health approaches. The Native Americans tend to focus on health and positive words, whereas Western methods often focus on diagnosis and disease. We talk about depression instead of happiness. In the Native American culture, counseling ability may be an inborn gift and developed in dreams and visions and through apprenticeship. There may not be formal counseling when you go on to a Native American reservation. You may find that there are people working as counselors who don't have a master's degree, and that's okay because that's not where they believe this skill comes from. They have an egalitarian view that all people have challenges. So, and transference is often uncommon, whereas we have this hierarchical view that some people have more challenges than other people and we tend to hold a power relationship. So there is going to be a transference to us potentially from our clients who have been more oppressed since we represent a power source. In the Native American culture, oversight of counseling and mental health services is done by the community, whereas we use licensing boards. Native Americans often use humor, insight, interpretation, plant medicine, prayer, ceremony, and transpersonal help from spiritual powers to accomplish the healing process. So they use a bunch of different things. It's not necessarily quite as serious, and this has got to get done as Western methods. Now, a lot of Western methods also use humor and insight and interpretation, but there's more nature. There's more spirituality often in the American Indian Native American population. Therapy on Native American populations, therapy is often practiced in nature or in a sanctified place using one to four non-time limited sessions on successive days, which is way different than what we do, where it's one hour, very predetermined session length, once a week, by-to-bing, by-to-bing, by-to-bing. Now, when we're trying to adjust and be culturally responsive to this, it's important to look at billable hours. You know, insurance companies are not going to pay for a three-hour session on Tuesday, a two-hour session on Wednesday, and a four-hour session on Thursday. They're just not going to do it. So we need to look at, you know, advocating, maybe, if the client would prefer or benefit from four successive sessions, seeing if we could get four hour-long sessions approved, that might go over well. Can't hurt to ask. Private pay is also an option, setting up different group sessions, you know, brief workshops or intensives, where somebody is there, you know, and generally intensives are private pay from Thursday until Sunday, and they have multiple hours that's a lot less structured than what we would normally do in, you know, our daily practice. Another difference is that Native Americans believe that advertising is unethical, whereas in order for us to have a practice, we have to advertise. We're on psychology today. We have a website. We have business cards, yada, yada. So that's just a little bit of a difference. We're probably not going to change the fact that we have to advertise, but we're also not going to be advertising on Native American reservations, and we're probably going to recognize that we're not going to reach Native Americans through advertising. We're going to reach them through word of mouth. They look for somebody who has had a similar experience to them. They look for somebody who has a good track record of resolving this particular issue. Now, we talked about generosity and stuff on one of the earlier slides. The selfless generosity of the healer and the patient promotes healing and outcome. There is no fixed fee for services. So the patient gives what he or she can or thinks is needed, and the healer accepts that, and the healer gives of him or herself freely and willingly to help the person get better. Whereas we tend to have a more cash on the barrel sort of approach. So that's another difference there. And in Native American cultures, it's not uncommon to see bartering and other things like that. In Native American culture, massage and laying of hands may be part of treatment. That is not part of treatment in Western cultures. We don't put hands on clients that starts to getting into all kinds of ethical and boundary issues. Now, if they want to incorporate massage and laying of hands, we can either incorporate their native healers or we can, you know, integrate a massage therapist into treatment, you know, somebody who's licensed to actually put hands on. So, you know, there are ways around it. We just need to be open to what they think is going to help them get grounded again and get back into harmony and balance. For the Native American, the focus is on returning to a state of confidence, balance, beauty, L being and harmonious family and community relations. So they're your treatment goals right there. You know, it's very different than the way we approach it in Western society where we would say, Okay, so we want to get you sleeping better, we need to get you eating better. We need to get you doing this. The focus here is on what needs to happen to return this state of balance and harmony. Native American medicine is a complete system that addresses both the healing and the cure. Knowing this, we need to understand that, you know, we're looking at a much broader thing. We're not just looking at a symptom here. Health requires balance in every sphere of one's life from the most personal inner world to lifestyle and even social connections. So all this is going to fall under the purview of potentially the medical practitioner as well as the mental health practitioner and the spiritual leader. Disease is not defined by physical pathology, but viewed from an expanded context that includes mind, body, spirit, emotions, social group and lifestyle. So they take it even further than biopsychosocial and they incorporate other things that really present a very holistic view. Native American medicine works by returning the individual to a state of balance within himself and in relationship to the outside world. And we're going to talk later in the week about Yin and Yang, but there's always, you know, two forces that work in harmony. For example, if you're a caregiver, you're giving a lot of yourself, but in order to be able to give of yourself, you also have to take care of yourself. So there's always a balance of how much energy do you give out versus how much energy do you get back and how much how much do you do to nurture and take care of yourself. So we're always talking about balancing the energy out with the energy in. Native American medicine places the roots of any imbalance in the world of the spirit. So spiritual interventions are seen as critical to the success of any treatment plan. Now obviously this isn't true of all Native Americans, but you know, like we talked about in the first thing, this is a generalization. It's a place to start thinking that, okay, this might need to be part of the treatment plan and then check it out with your client. The holistic approach seeks to create change, not only in pathology, but also in the patient's understanding of what's going on, what's causing this, how can I prevent it? How is this affecting my tribe, my family? We want to see a change in their attitude towards a healthier self-concept so they start feeling better about themselves because good energy is going to produce good energy. And we want to see an increase in appreciation of the world around him, the appreciation for things that people do for you, the appreciation for the fact that the sun rose today, focusing that attitude of gratitude that we sometimes talk about in Western medicine, increasing that connectedness and appreciation. This growth supports the patient in necessary behavior modifications. As people become happier and more appreciative and more understanding of the connections among things, they're likely going to make changes. You know, if you learned that eating a particular food was causing you to feel awful, you know, you're probably going to say, you know, I want to be happy. I want to be able to be there for my kids and not, you know, curled up in the fetal position on the sofa or something. And, you know, I want to don't want to negatively impact my family. And so in order to do that, I am going to stop eating this food. And you see that with people with Crohn's disease, for example, they have to cut certain foods out because it makes them ill. But the Native Americans would take it further and say, when you're ill, how does that negatively impact everything and everyone around you? So you don't want to do that. How can you make changes for the betterment of the tribe? The healer's intention is that the person not simply be cured of a problem, but be transformed through the experience of the disease. So they're going to grow. They're going to learn more about themselves and they're going to become more in harmony with the things around them. Someone in need of healing looks for a practitioner who's been successful in similar situations. So, you know, make sure that you have a good reputation. Now one thing that's a little bit different here is the healing elder is the culture's primary access to healing power. In a system without technology and standardized practice, the responsibility for treatment failure has often fallen squarely on the practitioner. So in Western medicine, we often say, well, the fault is, you know, the patient, the fault is the medicine, the fault is this. In Native American practice, the person who was supposed to be able to access the healing energies who failed to do so, they bear the responsibility. So motivational interviewing is a little bit different here. We have to help clients see where their responsibility lies and what they can do and empower them to a certain extent. Although Indigenous people differ greatly from one another, examples of ceremonies and ceremonies you can use to open sessions will help emphasize similarities between people and create a safe space where everybody feels respected and honored. This is from the motivational interviewing text and I thought it was important just to give you an example of three different ceremonies that can be used to open a group to help establish this safe space, if you will. The Pueblo example of an opening ceremony is an attempt to bring sacredness to the healing process when initially meeting with clients, acknowledging that we're entering a special place. As we enter this space, we leave all of our bad feelings and anger on the outside. We enter this space where we will be interacting with a clear mind and heart. We say our prayers asking our ancestors for their wisdom and help so that we may have a successful gathering. We ask the ancient ones to bring good energy, healing energy into our space and our time together. We put our thoughts and healing feelings together to become one. So this is a great ceremony or prayer to be said before starting a group treatment but it can also be said before starting an assessment. To help everybody kind of put, leave their stuff, check their stuff at the door so to speak and become one with the people in the room. The Marais, when the Marais people invite outsiders or even other Marais communities into their Marais, which is a special building for spiritual and community activities, they use a ceremony that reminds everyone that we are all one. Everyone is safe within the Marais and we all have the same goals. So we're all here for the same purpose. Each group introduces themselves and lets the other know that they come in peace. There's a specific process of talking back and forth and singing that I'm not going to go into right here. Near the end of this welcoming ceremony, each person from each group greets the other. The men touch noses, thereby breathing the same air and signifying that they are one. The women usually kiss the cheek. Then everyone goes to have tea and eat together. So this is one you obviously couldn't do at the beginning of every single group. But if you're working with a group that's primarily Native American, this might be the initial orientation group that you do in order to help everybody establish that sense of oneness. The day show uses ceremony where everyone is asked to stand up and form a circle. The leader addresses the people and emphasizes the importance of greeting and honoring each other and of acknowledging that we are all one in this world. The circle evolves into two circles that are connected. The person in the inner circle is the introducer while those in the outer circle listen. After you introduce yourself, you move into the outer circle. The first person begins to show the others what to do while the music plays. And there are different songs that can be played, but it helps people walk into the center, be the center of the unit, and have that power for a second, introduce themselves. Everybody gets to know one another. This is a good activity that can be done. Again, especially if it's a closed group where you can have the same people week after week, this can be done once. But it is helpful to get everybody on the same page and kind of learning the rules, so to speak. Another adaptation that can be done for motivational interviewing. You know, we have that readiness ruler that we use in motivational interviewing, pre-contemplation, contemplation, preparation, action, and maintenance. So the Native American version is thinking about planting for the season. Pre-contemplation, you haven't even prepared the ground yet. Contemplation, the seeds in the soil, but hasn't been watered. You know, you got some seeds there, but you're not really doing anything to tend it yet. Preparation, your plant just broke through the soil. It's not time to harvest yet. You know, harvest is the action phase. The plant just broke through the soil. It still needs a little nurturance before it's ready for harvest. And then action is when it's time for harvest. So this is one way of modifying the readiness ruler to help people kind of get oriented to what we're talking about at each stage of change. So another important thing to recognize is that most culture-bound syndromes associated with Native Americans were eliminated from the DSM-5. So you don't even have go-by guidelines in the DSM-5 now. There are a few that we're going to talk about here. There are probably many, many more. I do give you a couple of references on the next slide. Ghost sickness, which is more prominent in Navajo communities, happens when people are preoccupied and possessed by the deceased. Its symptoms include general weakness, loss of appetite, feeling suffocated, having recurring nightmares, and everlasting feeling of terror. It's believed that if the deceased did not get proper burial rites, their spirit would be doomed to remain on the living plane, staying to torture the living. So this is more than just grief. This is, you know, complicated grief if you want to put it in Western terms. Windigo psychosis. The windigo is a figure in North Algonquin mythology, which is a fierce supernatural cannibal able to infect humans and make them go into cannibalistic creatures by turning their hearts into ice. Windigo psychosis occurs when a person becomes filled with anxiety that they're becoming a windigo and may increasingly view those around them as edible. The person also complains of poor appetite, nausea, and vomiting and may become suicidal or homicidal. So obviously there are some psychotic features in there, but the root of the psychotic features, you know, you want to think in terms of bridging that gap. They believe it's a, the supernatural cannibal that is causing the psychotic issues. Heartbreak syndrome is another one. Pivotalk is a culture specific hysterical reaction in the Inuit especially, and especially in Inuit women who may perform irrational or dangerous acts followed by amnesia for the event. The condition appears most commonly in winter. So think, you know, seasonal effective disorder when there's less light, there may be some relation to that. Soul loss can be considered a helpful response because it allows the person's essence to remove itself from suffering and pain. In our book, Soul Retrieval, Sandra Ingraman describes soul loss as spiritual illness that causes emotional and physical disease and loss of crucial parts of ourselves that provide us with life and vitality. So if you feel like a part of you's just been ripped away. And there are ways to do soul recovery well beyond the scope of this particular presentation. Moth madness, frenzy witchcraft and fatigue from thinking too much are three other culture-bound syndromes that were brought up in the presentation issues in the diagnosis of Native American culture-bound symptoms that was in the Arizona Counseling Journal. You can find that online. You can find the presentation online. Barriers to treatment. American Indian women listed mistrust as one of the primary barriers to treatment due to impart to the women's belief that they would encounter people they knew among the treatment agency staff and doubted the confidentiality of the program. So this is kind of in contrary to the next one where many Native Americans believe that recovery cannot happen for individuals alone and their entire community has become sick. The healing forest model or metaphor says that one cannot take a sick tree from a forest, heal it and put it back in the same environment expecting that it will thrive. Because whatever was in that environment is probably what made it sick. So the same thing is true for people. So many Native Americans believe it takes the tribe to produce the recovery. It takes multiple people in the environment whereby you have individuals who don't want their confidentiality breached. So figuring out where your client sits in terms of confidentiality and the desire to have their family as part of treatment. Access is another barrier. The Indian Health Service is only on reservations where only about 20% of this population live. There are also a lack of American Indian Native American and Alaskan Native service providers and a lot of people in this culture prefer persons from their own culture. And Westerners tend to have culturally insensitive practices. A community approach which works well with this population leads to a reduction of substance use and mental illness. It can help break intergenerational cycles of alcohol abuse and mental health issues. Provides increased community support, strengthens the individual and group cultural identity, enhances leadership development, increases interpersonal and intertribal problem solving skills and solidarity. There's a lot of really awesome benefits to community approaches. So if you want to implement a community oriented approach, it's probably going to have multiple benefits and be received well. Native American cultural groups generally believe that health is nurtured through balance and living in harmony with nature and the community. They also for the most part have a holistic view of health. The approach that emphasizes culture is effective here because Native Americans believe culture is the path to prevention and treatment. Culturally responsive treatment should involve community events, group activities and the ability to participate in ceremonies to help clients achieve balance and find new insight. Recommending motivational interviewing, cognitive behavioral therapy and social learning approaches are all great for Native American clients because they have less cultural bias. They tend to focus on problem solving and skill development and emphasize strengths and empowerment. They recognize the need to accept personal responsibility for change and make use of learning styles written that many Native Americans find culturally appropriate. Many traditional healing activities and ceremonies have been made accessible during treatments or effectively integrated into treatment settings. One book that I like is the book of ceremonies, a Native way of honoring and living the sacred. You can find some techniques there. Obviously you're going to want to consult a Native American spiritual leader for guidance on understanding the spiritual nuances of these things. You're not just going to want to read a book and go with it. Practices can include sacred dances, the four circles which is up here. It integrates harmonious life in terms of four interlocking or overlapping circles. The talking circle or the medicine wheel. And the medicine wheel can be done not only as a text like this, but it can also be made on the ground so someone is sitting in the center of the medicine wheel or approaching certain aspects. Dancing with the wheel, a medicine wheel workbook is a really good primer overview of what that's about. Sweat lodges can also be used sometimes and they're intended as a religious ceremony for prayer and healing. The ceremony is only to be led by elders with many years of training who know the associated language, songs, traditions and safety protocols. So don't set one up at your clinic. The ceremony can be very dangerous and deadly if performed improperly. Sweat lodges have also been used by some non-Natives resulting in responses from Indigenous elders declaring that it is dangerous and disrespectful. There are similar practices in the cultures in Mexico and Central America that aren't called specifically sweat lodges. But we do want to recognize that this is a practice that is revered in this culture. We are not trained or skilled or able to implement it, but it might be something our clients would want to experience. So we need to know how to refer them to their tribal nation where they can find out how to access it. And other purification practices may also be included because remember the mind, body and spirit are all one. So we need to purify the body as well as purifying the mind, the thoughts and purifying the spirit. American Indians place a high value on family and extended family networks. So restoring or healing family bonds can be very therapeutic. Whereas the person may be feeling a whole bunch of stress and their strife in the family. If you can heal these family bonds, that weight may be lifted off the person. The Native American concept of family can include elders, others from the same clan or individuals who are not biologically related. In many tribes, all members of the tribe are considered relatives. So we need to look at who do you want involved in your treatment. Family therapy models such as network therapy, which makes use of support structures outside of the immediate family and was originally developed for Native American families living in urban communities can be particularly effective with Native clients. So encouraging them to develop their network. Many Native American tribes and traditional healing practices that involve groups and healing need to occur within the context of the group or community. Go figure. If properly adapted to incorporate Native American traditions, group therapy can be very beneficial and culturally congruent, such as talking circle is something I didn't really even know we were using in the facility I used to work at. But it's the tradition where members of the group sit in a circle and a feather stone or other symbolic item is passed around and each person speaks when he or she is handed the item. You can earn support or permission from tribal authorities before organizing group therapy, and you really should also consult with Native professionals to see how this group. You know, if you're working with a group of Native Americans from a particular community, you want to make sure that it's interfacing with the rest of the tribe and how all that's going to fit together. Obviously releases of information and everything apply. If group members consent, invite respected tribal members such as traditional healers or elders to participate in sessions. When it comes to mutual help and support, more Alaskan Natives in Recovery reported participation in 12 step groups than in substance abuse treatment. Partly because it's probably more accessible, but they are willing to go to 12 step groups where they do feel a certain bond and unity. 84% of respondents on one survey had attended some sort of mutual help meetings. So again, this is actually way higher than in the majority culture. I'm not going to read the different 12 steps the Lakota tribe has adapted the 12 steps to fit their spiritual viewpoint. So I compared them on the next two slides, the traditional 12 steps on one side and the Lakota tribe on the other. A lot of it is referring instead of to God and him. It talks about the Great Spirit. So what can we do to help this population or to be more culturally responsive? We already talked about the assessment. You don't want to just meet somebody and from get go and start saying, okay, let's start talking. And I'm going to start asking you all these really in depth personal questions. Now they probably know that there's going to be a certain amount of that. So, you know, there's some navigation there, but you want to spend some time getting to know the person and letting them get to know you a little bit before launching into that. If you can provide sessions on successive days, even if they have to be time limited, because we all have billable hours and people were accountable to him. That can help make it more culturally responsive. Incorporating native healers getting assigned release of information to talk with the spiritual leader or tribal elder that the person belongs to if that's appropriate. Refrain from asking questions about family or personal matters unrelated to the presenting issue without first asking the client's permission to inquire about those areas. So if you're off on left field asking questions and some of our assessments can kind of get, you know, off track when you're taking a medical history of your father's family or something. You want to explain to the client how this question you're asking relates to the current issue. You're not just being nosy. It's helpful in formulating your case plan for XYZ reason. Pay attention to the client's stories, experiences, dreams and rituals and their relevance to the clients. Some clients will have a huge faith in their dreams that we need to pay attention to or their rituals. Some not so much, but we do need to listen and understand where this culture derives their meaning. Remember that Native Americans are often visual learners, so provide handouts and visual explanations whenever possible. If you're trying to explain something, you may want to write it down. If you're trying to explain the ABC technique of cognitive behavioral, hand them a worksheet so they can look at it. Give them as much printed material as possible so they can read it in their, in their own time. When possible, use diagrams, you know, node mapping, things like that, or you may call it mind mapping to help them see and draw connections between things that will accommodate their visual learning in the counseling session. So if you have a whiteboard, make use of it. You have to have extended periods of silence during sessions because they're going to need time to think. After you finish speaking, the respondent has control over the conversation, so let them think and then they'll respond. Don't jump in too soon. Allow time during sessions for the client to process information. You know, kind of goes without saying. When you greet clients, greet them with a gentle handshake and show hospitality. That firm handshake that we value in Western cultures isn't valued in many other cultures. So greet them with a gentle handshake and show hospitality. If you're able to offer them bottled water or something, great. Otherwise, make sure that they feel like they can make themselves comfortable in your office. Give the client ample time to adjust to the setting at the beginning of each session, not just the assessment. But when they come in, make a little chit chat for a couple of minutes. Let them get kind of settled and into the groove. Keep your promises. Offer suggestions instead of directives and preferably more than one so the client can choose. Give them a menu of options. There's that motivational interviewing again. If you're not native or from a different tribe, you might invite your client to share what is it like to be working with me as your counselor. And talk about that for a little while. Obviously you don't have to talk about that at every session, but it might be a way to kind of get to know one another a little bit more before getting into the nitty gritty. Cultural differences in the expression and reporting of distress are well established among American Indians and native Alaskan tribes. These often comprise, compromise the ability of assessment tools to capture the key signs and symptoms of mental illness. For example, the words depressed and anxious don't even exist in certain American Indian and Alaskan native languages. So one thing you can do in order to try to capture the symptomatology a little bit better. There is a cultural formulation interview in the DSM five and the link goes directly to it. It's online. You can see it if you don't have a DSM five handy. But it helps you figure out what questions to ask in order to get at what you're trying to figure out so you can fulfill the insurance requirements. And since they tend to focus on health and recovery and harmony is instead of diagnosis and pathology, but we have to bill. I do talk about that with them and help them understand that, you know, I've got to do this in order to bill for services. But let's talk about what your concept of recovery looks like. So we want to help clients, but we need to learn at intake. And you notice I said, we do, they don't. Well, they could, but we need to listen to each client from his or her cultural perspective, including their perception of the problem and treatment preferences. We need to explain at the beginning, the overall purpose of the interview and intake process, get them socially oriented. Acknowledge clients concerns and discuss the probable differences between you and your clients and take time to understand each client's explanatory model of illness and health. Where do you believe this came from? What do you think is causing your symptoms? And that's in the DSM five assessment. Identify a recommended course of action through collaboration and negotiate a treatment plan that leaves the client's cultural norms and life ways into treatment goals, objectives and steps. Notice it says the client's cultural norms, not the culture's norms. So we want to look at what does the client embrace and hold on to. Respect the clients by understanding and reflecting what their concerns are and understand how respect is shown within different cultures. Explanatory model is E in respect. Devote understanding to how clients perceive their presenting issues, the origin, impact and treatment. Sociocultural context. Recognize how class, race, ethnicity, gender, education, socioeconomic status, et cetera, affect care. Acknowledge the power differential between clients and counselors. Express empathy, you know, we do that. Elicit clients' concerns and apprehensions. Ask them, you know, what are your concerns because they may not bring them up and develop that therapeutic alliance. Native American clients are collectivistic valuing family and tribe that experience oppression on a regular basis and have the highest rate of SIDS. Native Americans often do well academically until middle school at which point their academic achievement and mental health status begin to worsen. Early intervention and culturally appropriate teaching practices can assist in reducing this trend. Group and family interventions can be helpful and we should review differences in worldview and counseling approaches prior to working with this population. Thank you all for bearing with me. I thought I was going to make it without coughing through the presentation, but so much so. Are there any questions? The articles that I mentioned in the presentation as well as a ton of other articles are in the additional resources section of your course. And if you came in a little bit late, I will be making a eight to 10 hour course on just working with Native Americans that hopefully will be out, you know, around February of next year. Alrighty everybody, have a great day and I will see you tomorrow. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com providing 24 seven multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselor toolbox to get a 20% discount off your order this month.