Child, Adolescent & Family

Executive Summary

Volume I: Cultural Strengths and Challenges in Implementing a System of Care Model in American Indian Communities

Introduction

Reports show that mental health services for Indian children are inadequate, despite the fact that Indian children are know to have more serious mental health problems than all other ethnic groups in the United States.¹ This monograph examines five American Indian children’s mental health projects funded by the Center for Mental Health Services (CMHS). These projects hold the promise of changing that picture. These projects have developed extraordinarily creative and effective systems of care largely based in their own cultures and on the strengths of their families. The contributions of these projects are important because they teach us ways of overcoming the severe mental health problems faced by our communities and provide models for replication.

The goal of this work is to examine promising practices that implement traditional American Indian helping and healing methods that are rooted in their culture. The CMHS’s emphasis on cultural competence has opened the door to the demonstration and acceptance of these cultural resources as important and viable community-based approaches. As a result, American Indian grant sites are merging the systems of care model with their own local cultures and using traditional helping and healing practices that are embedded in thousands of years of Indian culture and knowledge.

This monograph presents the strengths and challenges of community-based service designs that draw on culture as a primary resource. However, cultural competence, as it applies to American Indian communities, is more complex than it first appears. The complexity stems from the enormous diversity between tribes, as well as within our communities. Despite the diversity, American Indian authors and communities have documented in recent years that traditional Indian wellness teachings and healing practices form an important component of physical and mental health care for Indian people. ^2,3 The pertinent literature is reviewed here, and it suggests that the American Indian sites described here are not alone in their pursuit of culturally-based mental health methods.

Methodology

As a theoretical framework, the authors use the relational model (often associated with the medicine wheel), which is based in the traditional American Indian worldview. The relational model describes mental health as a balance among context, mind, body, and spirit. This conceptual framework organizes the investigation of how grantees are using cultural interventions in their programs. Data from four of the five sites were obtained from focus groups and key informant interviews. Data from one site were gathered from written materials. The focus groups consisted of groups of parents, children, service providers, community members, and staff from collaborating programs, in various combinations. Key informants, including medicine people, elders, and other important community members, also were interviewed. Questions were designed to elicit information relating to the four quadrants of the medicine wheel, in the areas of context, mind, body, and spirit.

The Projects

The K’e Project provides culturally relevant, comprehensive, community-based behavioral/mental health and related services to children of the Navajo Nation, the largest American Indian reservation in the United States. K’e means to have reverence for all things in the universe and to maintain balance and harmony by acknowledging and respecting clan and kinship.

Kmihqitahasultipon ("We Remember") is a culturally-based system of care for children and their families located in Indian Township, Maine. It serves members of the Passamaquoddy Tribe and draws heavily upon the community for mentors and respite care providers.

Sacred Child Project is a strengths-based, community empowerment project that is rooted within the wraparound philosophy and coordinated by the United Tribes Technical College in North Dakota. It serves the Spirit Lake Nation, Standing Rock Nation, Three Affiliated Tribes, Turtle Mountain Band of Chippewa and Trenton Indian Service Area.

With Eagle’s Wings is a culturally-appropriate program delivering wraparound services to children, youths and their families. Located on the Wind River reservation in Wyoming, it serves the Northern Arapaho Nation.

Mno Bmaadzid Endaad is a project of The Sault Ste. Marie Tribe of Chippewa Indians, in partnership with the Bay Mills Tribe of Chippewa Indians, located in the Upper Peninsula of Michigan. Mno Bmaadzid Endaad means "Be in Good Health at His House."

The projects, though different in stage of development, design and populations, are strikingly similar in their strategies to use culture as a resource for helping.

Findings

In reviewing the responses of each site, we identified several recurring themes. The themes revealed 18 identifiable promising practices that address the integration of culture as a resource for helping children and their families. They are listed below, organized by the relational model.

Context

Use of extended family and extended family concept (context)
Use of cultural restoration, via mentors, groups and crafts (context, body)
Use of methods that build connection to community, culture, group, clan and extended family (context)
Use of elders or intergenerational approaches (context)
Use of helping values from traditional teaching such as 24-hour care and self-care (context)
Use of approaches that strengthen or heal the community (context)
Incorporation of a value of respect for in-group diversity and exercising that value in services (context)

Mind

Use of specific cultural approaches (mind, spirit, body)
Use of cultural adaptations to mainstream system of care practices such as wraparound, respite, crisis intervention and collaboration (mind, context)
Use of methods to promote healing of Indian identity and development of positive cultural self-esteem (mind)
Use of methods that build up the sense of dignity and strength (mind)
Use of methods that prepare children to live in two cultures and cope with racism and prejudice (mind, context)
Use of the native language (mind)
Use of all of the above, along with conventional services such as counseling, therapy and health care (mind)
Use of conventional and cultural methods to recognize and treat historic cultural, intergenerational and personal trauma (mind, body, context, spirit)

Body

Maintenance of an alcohol-and drug-free event policy, and dealing with substance abuse (mind, body)
Use of specific cultural approaches such as sweat lodges, feasts, etc. (body, mind, spirit)

Spirit

Use of traditional teachings that describe wellness, balance, and harmony or that provide a mental framework for wellness and use these as objectives for the families (spirit, mind)
Use of methods that invoke the positive effects of spiritual belief or tap into spiritual strengths or support (spirit)
Use of specific cultural approaches such as talking circles and ceremonies (spirit, mind, body)

This monograph is the story of communities reaching into the richness of their cultural teachings and finding new expressions for use in modern services and practices. For example, kinship networks and clan systems are being used as resources to provide respite care. Service providers and families are learning how traditional wellness concepts can facilitate a strengths-based approach to family harmony. Tools such as storytelling, ritual and ceremony, rites of passage and kinship support are being applied in a modern system of care.

Questions and Next Steps

An investigation such as this always raises new questions. Staffing issues, supervision, training, burnout and boundaries must be addressed in the cultural context of American Indian communities. Management issues such as leadership, organizational structure and integrity, and collaboration need to be examined. Funding strategies must be considered. And, of great importance, the interface between these practices and Medicaid reimbursement and managed care must be considered by policy makers and project directors if sustainability is to be achieved.

These promising practices need to gain legitimacy in mainstream America and be seen as viable and credible programs rather than mere experiments or expendable add-ons. There are strong indications that these community-based, culturally-rooted programs, with 24-hour wraparound service availability, result in substantial cost savings by preventing more costly, out-of-home services. To that end, the services must be evaluated effectively, understanding of course that culturally-appropriate evaluation tools and methodologies are prerequisites to effective evaluation.

Footnotes

¹ Swinomish Tribal Mental Health Project. (1991). A gathering of wisdoms, tribal mental health: A cultural perspective. La Conner, Washington: The Swinomish Tribal Community.

² Swinomish Tribal Mental Health Project. (1991).

³ Earle, K. A. (1996, Fall). Working with the Haudenosaunee: What social workers should know. The New Social Worker.