CHAPTER 4

Mental Health Care for American Indians and Alaska Natives

Conclusions

As evidenced through history and current socioeconomic realities, American Indian and Alaska Native nations have withstood the consequences of colonialism and of subsequent subjugation by the U.S. Government. Many members of this minority population are regaining control of their lives and rebuilding the health of their communities.

1.   Although relatively little evidence is available, the existing data suggest that American Indian and Alaska Native youth and adults suffer a disproportionate burden of mental health problems compared with other Americans. Because of the unique and painful history of this minority group, many of its members are quite vulnerable. Given the high rates of suicide documented among some segments of this population, they are likely to experience increased need for mental health care as compared with white Americans. Yet, in sharp contrast to other minority groups and the general population, there is a lack of epidemiology and surveillance. This information is needed to understand the nature, extent, and sources of burden to mental health, as well as concomitant disparities. This is true across the developmental lifespan.

2.   Those who are homeless, incarcerated, and victims of trauma are particularly likely to need mental health care. Indian and Native people are overrepresented in these vulnerable groups. It is not known whether they receive mental health care within the institutions intended to serve them, but there appears to be considerable unmet need. Research is needed to understand the paths by which American Indians and Alaska Natives reach these points. Just as important, methods for detecting and managing their mental health are needed in related institutional settings through culturally appropriate ways that both ameliorate their present burden and protect them from the future consequences of adversity.

3.   There is significant comorbidity in regard to mental and substance abuse disorders, notably alcoholism, among both Native youth and adults. There is some indication that disorders occurring together are unlikely to be addressed by most mental health or substance abuse treatment settings. This underscores an important unmet need. Neither philosophies of treatment nor funding streams should preclude the timely and culturally appropriate treatment of such comorbidities, which otherwise threaten successful, lasting intervention.

4.   Little is known about either the use of mental health services by American Indians and Alaska Natives, or whether those who need treatment actually obtain it. However, the available research has important implications. First, practical considerations, such as availability of culturally sensitive providers and accessibility of services through insurance or geographic location, are extremely important for this ethnic group. Second, services for those in greatest need of care may best be provided within targeted settings, such as those serving the homeless, incarcerated, or alcohol dependent. Medical services that provide care for victims of trauma or older primary care patients also hold promise for meeting the needs of a significant portion of this population.

5.   Major changes in the financing and organization of mental health care are underway in American Indian and Alaska Native communities as a con-sequence of relatively recent policies regarding self-determination. There is limited understanding of these changes, their implications for resources, the resulting continuum of care, or the quality of services. Thus, it is imperative that organizational and financing changes be closely examined with an eye toward the best interests of Native people. It would be a sad legacy to conclude 20 years from now that the assimilationist pressures that proved so devastating in the past have been unwittingly repeated.

6.   The knowledge base underpinning treatment guidelines for mental health care have been built with little specific analysis of their benefit to ethnic minority groups. The evidence behind them is an extrapolation from largely majority clinical populations. This is in spite of the fact that cultural forces are known to be at work in virtually every aspect of psychopathology, from risk to onset, presentation, assessment, treatment response, and relative burden. Moreover, the efficacy of treatment alternatives that may be especially relevant to this population has not yet been examined. Accordingly, clinical research needs to be undertaken to shed light on the applicability and outcomes of treatment recommendations for American Indians and Alaska Natives.

7.   Though long-suppressed by social and political forces, traditional healing practices and spirituality are strongly evident in the lives of American Indians and Alaska Natives. They usually complement, rather than compete with, medical care. The challenge is to find ways to support and strengthen their respective contributions to the health and well-being of those in need. How well this is accomplished depends on advances in the science by which healing practices and spirituality are conceptualized and examined.

8.   Despite the mental health problems that plague Indian and Native people, the majority, though at risk, are free of mental illness. Thus, prevention should remain a high priority. Native voices are clear and unequivocal in this regard; preventive and promotive approaches strike a resonant chord in the hearts of these individuals and their communities. Abundant evidence attests to the creativity of intervention strategies mounted in an attempt to ameliorate situations of develop-mental risk for mental health problems among American Indians and Alaska Natives. Unfortunately, the current limits of science, notably the conceptualization and measurement of both the culturally defined and relevant points of intervention as well as outcomes, impede the evaluation of these strategies. Here the challenge is to understand how preventive interventions developed in other populations work for the American Indian and Alaska Native population in order to determine what adaptations must be made to improve their cultural fit and effectiveness. Conversely, the country as a whole has a great deal to gain by attending to advances in prevention among American Indians and Alaska Natives, for the lessons learned in these instances may have broader application to all Americans.

9.   Lastly, the individual and collective strengths of Native communities warrant closer, systematic attention. Interventions are needed to promote the strengths, resiliencies, and other psychosocial resources that characterize full, productive, meaningful lives and contribute to their maintenance. New perspectives need to be explored, bending our scientific tools to the task.

American Indian and Alaska Native people speak about a journey as beginning with its initial steps. With respect to mental health, this journey already has begun. Some paths have been well traveled and feel familiar; some paths are new and intriguing; some paths have yet to be marked. It is clear that the Nation can serve as a guide for hastening this journey along certain paths. It is equally clear that the Nation would also do well to watch carefully and follow Native people along the paths that they have emblazoned.