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There are 566 federally recognized American Indian Tribes, and their members speak more than 150 languages, and numerous other Tribes recognized only by states and others that still go unrecognized by government agencies of any sort. Native Americans who belong to federally recognized Tribes and communities are members of sovereign Indian nations that exist within the United States. On lands belonging to these Tribes and communities, Native Americans are able to govern themselves, and health care is provided by the Indian Health Services (IHS),

Prevalence of Problems
28.3 percent of American Indians and Alaska Natives report having a mental illness, with approximately 8.5 percent indicating serious mental illness in the past year
Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial/ethnic populations, and more than 10 percent reported a major depressive episode in the past year.
Common disorders include depression, anxiety, and substance use.
PTSD comparison rates taken from the AI-SUPER PFP study show that 12.8 percent of the Southwest Tribe sample met criteria for a lifetime diagnosis of PTSD compared with 4.3 percent of the general population
American Indians and Alaska Natives have the second highest infant mortality rate in the Nation (National Center for Health Statistics, 1999) and the highest rate of sudden infant death syndrome which contributes to additional trauma, depression and anxiety in families.

Native Americans are less likely than other Americans to graduate high school or complete a college degree. This is interesting becaause, American Indian students achieve on a par with or beyond the performance of non-Indian students in elementary school, but show a decline in performance between fourth and seventh grades. It is thought that American Indian children may have a culturally rooted way of learning at odds with teaching methods currently used in public education. For example, they are primarily visual learners, whereas the public education system uses auditory methods of teaching.

Poverty is another contributor to stress. The poverty rate for America as a whole is 14.3% (Center for Poverty Research), for Native Americans the rate is about 26%. Native Americans have the lowest employment rate of any racial or ethnic group in the United States (Bureau of Labor Statistics, 2012). In the poorest Native counties, only about 1/3 of men in Native American communities have full-time, year-round employment.

Historical reasons for the development of binge drinking among Native Americans include the existence of dry reservations (which can limit the times when individuals are able to get alcohol), high levels of poverty, lack of availability (e.g., In remote Alaskan native villages), a history of trauma (personal and intergenerational), and the loss of cultural traditions.

Many Native American children were separated from their families and sent to boarding schools. Due to this separation from their families, when these children become parents themselves, they are not able to draw on experiences of growing up in a family to guide their own parenting which increases the risk for domestic violence, spousal abuse, and family instability, with their attendant negative mental health effects. This is evidenced by the fact that 6 in 10 American Indian and Alaska Native families were headed by married couples vs. 8 in 10 of the Nation's other families

Other health disparities include:
Heart disease
Unintentional injuries
Depression, anxiety, PTSD and suicide
Substance abuse
Sudden infant death syndrome (SIDS)
Teenage pregnancy
Liver disease
60% higher infant mortality rate than Caucasians
5.8 tuberculosis rate compared to 2.0 for Caucasians (2010)
Diabetes which is also associated with depression, is increasing among Native Americans, and approximately 38 percent of elder Native Americans have diabetes

Specific Native American Values
Native Americans generally value the community’s best interests over their own interests (collectivistic). When an individual is experiencing problems it interferes with his or her ability to fulfill his or her role in the community. Many believe that addiction or mental health problems hurt and weaken the community. 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.

Amerrican Indian/Alaskan Native Worldview can be described by the following characteristics:
Relational problem solving
Mind/Body/Spirit is one
Mysticism/Acceptance of life and illness
Ceremonies/Rituals for treatment
Tribal Connectedness as a lifestyle and organizing force
Spirituality and Balance influences values
Cooperation/Sharing is the goal
Patience/Respect in interactions
Present Orientation
Healing through Herbs, Plants, Nature

American Majority Culture Worldview can be desccribed by the following characteristics
Linear Point A to Point B
Psyche is the focus of treatment
Science/Verification of illness and being
Psychotherapy for treatment
Individualism as a lifestyle and organizing force
Organized religion influences values
Competition/Winning is the goal
Assertiveness/Forcefulness in interactions
Future Orientation
Psychopharmacology for healing

Communication Guidelines
You should know someone well before speaking to them for long periods of time or confiding in them
Children should not display themselves verbally in front of adults.
It is inappropriate to express emotions in public or around people you don't know very well, verbally or non-verbally.
Don’t ask direct questions or expect an immediate response from people you don't know very well.
It is inappropriate to verbally discipline or praise a child in public.
It is inappropriate to speak for someone else, no matter who that person is. Everyone is titled to their own opinion, even a child.
“In Indian conversations, it is not the person who speaks first who necessarily controls the topic. This is because an immediate response to what someone ha said may be delayed. The respondent therefore has control over the topic by choosing when to speak and what to say.“
Do not call someone out directly
Do not compete with answers, no answer can be said it is wrong
Do not look directly at someone the entire time they are talking.

Be careful when bringing up the topic of spirituality, as there are sacred and secret traditional practices and spiritual leaders who have the role of providing guidance and healing. Many Native communities have long histories of contact with missionaries. They may have adopted, rejected or blended Christian beliefs with their own Native beliefs. In general, belief in the Creator, Grandfather, God, gods or a higher power is central to many Native people. For some Native Americans, spirituality is an integral part of who they are and the world around them. Native healers do not separate mind, body and spirit but see them all as connected.

Native Americans & Addiction
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 is the only way people know how to cope with their problems. Eduardo and Bonnie Duran wrote about addiction as a spirit in their book, “Native American Postcolonial Psychology.” Native American recovery movements viewed addictions as a result of cultural conflict between Native and Western cultures, seeing substances as weapons that have caused further loss of traditions. To best treat this population embrace a broader view that explores the spiritual, cultural, and social ramifications of substance abuse. Talking about how current behaviors interfere with their spirituality may help increase client’s motivation to make positive changes

Differences in Mental Health Approaches

Native Americans ascribe to the egalitarian view that all people have challenges. Healing is accomplished through insight, humor, positivity interpretation, plant medicine, prayer, ceremony, and transpersonal help from spiritual powers. The focus is on health, returning to a state of confidence, balance, beauty, well-being, and harmonious family and community relations.

Unlike Western cultures, aounseling ability may be an inborn gift, developed in dreams and visions and through apprenticeship and is managed through oversight by the community

Therapy is generally practiced in nature or a sanctified place in 1-4 random-length sessions on successive days and may include massage or laying of hands. It is believed that selfless generosity of the healer and patient promotes healing and outcome

Native American medicine is a complete system that addresses both healing and cure. Health requires balance in every sphere of one’s life, from the most personal inner world to lifestyle and social connections. Further, disease is not defined by physical pathology, but viewed from an expanded context that includes body, mind, spirit, emotions, social group, and lifestyle. Native American medicine works by returning the individual to a state of balance both within himself and in relationship to the outer world, placing the roots of any imbalance in the world of spirit. Spiritual interventions are thus seen as critical to the success of any treatment plan.

This holistic approach seeks to create a change not only in pathology, but also in the patient’s understanding of how to remedy the disharmony, development of a healthier self-concept, and appreciation of the world around him. The healer’s intention is that the person be not simply cured of a disease, but transformed through the experience of disease.

Opening ceremonies and rituals can emphasize similarities among people and creating a safe space where everyone feels respected and honored.

Culture Bound Syndromes
Most “culture-bound” syndromes associated w/ Native Americans eliminated from DSM V
Ghost Sickness (Navajo) is one culture bound syndrome. People that are preoccupied and possessed by the deceased are considered to have Ghost Sickness. Its symptoms include general weakness, loss of appetite, feeling suffocated, having recurring nightmares, and an everlasting feeling of terror. It is believed that if the deceased did not get proper burial rights, their spirit would be doomed to remain on the living plane, staying to torture the living.

Windigo Psychosis is another issue that may arise for Native Americans. “The Windigo is a figure in Northern Algonquin mythology, a fierce supernatural cannibal able to infect humans and make them into cannibalistic creatures by turning their hearts into ice. Windigo Psychosis occurs when a person becomes filled with anxiety that they are 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.”

Other culture bound syndromes include:
Heartbreak Syndrome
Pibloktoq (arctic hysteria)
Soul loss
iich’ aa (moth madness (Navajo))
“Frenzy” witchcraft (Navajo)
Fatigue from thinking too much
From Thomason, T. (2014). “Issues in the Diagnosis of Native American Culture Bound Syndromes. Arizona Counseling Journal

Barriers to Treatment
American Indian women listed mistrust as one of the primary barriers for seeking treatment. This is due, in part, to the women's belief that they would encounter people they knew among treatment agency staff; they also doubted the confidentiality of the treatment program. For this reason it is vital to ensure confidentiality and set up programs in a way that provides the most privacy.

While some resist treatment for fear of exposure, many other Native Americans believe that recovery cannot happen for individuals alone and that their entire community has become sick. The “healing forest” model says that one cannot take a sick tree from a sick forest, heal it, and put it back in the same environment expecting that it will thrive. The same is true for people. Recovery is not only about transformming the individual, but transforming the system, or getting it back into harmony.

Community approaches often lead to:
A reduction of symptoms.
Breaking intergenerational cycles of alcohol abuse.
Increased community support.
The strengthening of individual and group cultural identity.
Leadership development.
Increased interpersonal and inter-Tribal problem-solving skills and solidarity.

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. Recommend treatments include Motivational Interviewing, cognitive behavioral therapy and social learning approaches because they have less cultural bias, a focus on problem-solving and skill development, emphasize client strengths and empowerment, make use of learning styles that many Native Americans find culturally appropriate. To make treatment more culturally responsive many traditional healing activities and ceremonies can be included in treatment or treatment settings including
Sacred dances
The four circles (a model for conceptualizing a harmonious life)
The talking circle
Medicine Wheel (See Dancing with the Wheel: a Medicine Wheel Workbook )
Sweat lodges (by trained practitioners)
See The Book of Ceremonies: a Native Way of Honoring and Living the Sacred for some techniques

American Indians place high value on family and extended family networks, so restoring or healing family bonds can be therapeutic. 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 are considered relatives.

Advice to Counselors
Avoid interrupting, extensive note-taking or excessive questioning
Refrain from asking about family or personal matters unrelated to the presenting issue without first asking the client's permission to inquire about these areas.
Pay attention to the client's stories, experiences, dreams, and rituals and their relevance to the client.
Remember that Native Americans are often visual learners, so provide handouts and visual explanations
Accept extended periods of silence during sessions.
Allow time during sessions for the client to process information.
Greet the client with a gentle (rather than firm) handshake and show hospitality (e.g., by offering food and/or beverages).
Give the client ample time to adjust to the setting at the beginning of each session.
Keep promises.
Offer suggestions instead of directions (preferably more than one to allow for client choice)
If you are not Native or are from a different tribe, you might invite your client to share what it is like for him or her to be working with you as their counselor.

LEARN at Intake
Listen to each client from his or her cultural perspective, including perception of the problem and treatment preferences
Explain the overall purpose of the interview and intake process.
Acknowledge client concerns and discuss the probable differences between you and your clients. Take time to understand each client's explanatory model of illness and health.
Recommend a course of action through collaboration with the client including how much involvement he or she has in the planning process
Negotiate a treatment plan that weaves the client's cultural norms and lifeways into treatment goals, objectives, and steps.

Respect—Understand and reflect how respect is shown within given cultural groups through verbal and nonverbal communications.
Explanatory model—Devote to understanding how clients perceive their presenting problems issues, their origin, impact and treatment
Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic status etc. affect care.
Power—Acknowledge the power differential between clients and counselors.
Empathy—Express, verbally and nonverbally, the significance of each client's concerns so that he or she feels understood by the counselor.
Concerns and fears—Elicit clients' concerns and apprehensions regarding help-seeking behavior and initiation of treatment.
Therapeutic alliance/Trust—Commit to behaviors that enhance the therapeutic relationship; recognize that trust is not inherent but must be earned by counselors.