CHAPTER 4

Mental Health Care for American Indians and Alaska Natives

The Need for Mental Health Care

Historical and Sociocultural Factors That Relate to Mental Health

The history of American Indians and Alaska Natives sets the stage for understanding their mental health needs. Past governmental policies regarding this population have led to mistrust of many government services or care provided by white practitioners. Attempts to eradicate Native culture, including the forced separation of Indian and Native children from parents in order to send them to boarding schools, have been associated with negative mental health consequences (Kleinfeld, 1973; Kleinfeld & Bloom, 1977). Some argue that, as a consequence of past 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 (Special Subcommittee on Indian Education, 1969). The effect of boarding school education on American Indian students remains controversial (Kunitz et al., 1999; Irwin & Roll, 1995).

The socioeconomic consequences of these historical policies are also telling. The removal of American Indians from their lands, as well as other policies summarized above, has resulted in the high rates of poverty that characterize this ethnic minority group. One of the most robust scientific findings has been the association of lower socioeconomic status with poor general health and mental health. Widespread recognition that many Native people live in stressful environments with potentially negative mental health consequences has led to increasing study and empirical documentation of this link (Manson, 1996b, 1997; Beals et al, under review; Jones et al., 1997).

Key Issues for Understanding the Research

Because American Indians and Alaska Natives comprise such a small percentage of U.S. citizens in general, nationally representative studies do not generate sufficiently large samples of this special population to draw accurate conclusions regarding their need for mental health care. Even when large samples are acquired, findings are constrained by the marked heterogeneity that characterizes the social and cultural ecologies of Native people. There are 561 federally recognized tribes, with over 200 indigenous languages spoken (Fleming, 1992). Differences between some of these languages are as distinct as those between English and Chinese (Chafe, 1962). Similar differences abound among Native customs, family structures, religions, and social relation-ships. The magnitude of this diversity among Indian people has important implications for research observations. Novins and colleagues provide an excellent illustration of this point in a paper that shows that the dynamics underlying suicidal ideation among Indian youth vary significantly with the cultural contexts of the tribes of which they are members (Novins, et al., 1999). A tension arises, then, between the frequently conflicting objectives of comparability and cultural specificity—a tension not easily resolved in research pursued among this special population.

As widely noted, language is important when assessing the mental health needs of individuals and the communities in which they reside. Approximately 280,000 American Indians and Alaska Natives speak a language other than English at home; more than half of Alaska Natives who are Eskimos speak either Inuit or Yup’ik. Consequently, evaluations of need for mental health care often have to be conducted in a language other than English. Yet the challenge can be more subtle than that implied by stark differences in language. Cultural differences in the expression and reporting of distress are well established among American Indians and Alaska Natives. These often compromise the ability of assessment tools to capture the key signs and symptoms of mental illness (Kinzie & Manson, 1987; Manson, 1994, 1996a). Words such as “depressed” and “anxious” are absent from some American Indian and Alaska Native languages (Manson et al., 1985). Other research has demonstrated that certain DSM diagnoses, such as major depressive disorder, do not correspond directly to the categories of illness recognized by some American Indians. Thus, evaluating the need for mental health care among American Indians and Alaska Natives requires careful clinical inquiry that attends closely to culture.

Census 2000 reports a significant increase in the number of individuals who identify, at least in part, as American Indian or Alaska Native. This finding resurrects longstanding debates about definition and identification (Passel, 1996). The relationship of those who have recently asserted their Indian ancestry to other, tribally defined individuals is unknown and poses a difficult challenge. It suggests a newly emergent need to consider the mental health status and requirements of individuals who live primarily within mainstream society, while continuing to build the body of knowledge on groups already defined.

Mental Disorders

Although not all mental disorders are disabling, these disorders always manifest some level of psychological discomfort and associated impairment. Such symptoms often improve with treatment. Therefore, the presence of a mental disorder is one reasonable indicator of need for mental health care. As noted in previous chapters, in the United States such disorders are identified according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic categories established by the American Psychiatric Association (1994).

Adults

Unfortunately, no large-scale studies of the rates of mental disorders among American Indian and Alaska Native adults have yet been published. The discussion at this point must rely on smaller, suggestive studies that await future confirmation.

The most recently published information regarding the mental health needs of adult American Indians living in the community comes from a study conducted in 1988 (Kinzie et al., 1992). The 131 respondents were inhabitants of a small Northwest Coast village who had participated in a previous community-based epidemiological study (Shore et al., 1973). They were followed up 20 years later using a well accepted method for diagnosing mental disorders, the Schedule for Affective Disorders and Schizophrenia-Lifetime Version. Nearly 70 percent of the sample had experienced a mental disorder in their lifetimes. About 30 percent were experiencing a disorder at the time of the follow-up.

The American Indian Vietnam Veterans Project (AIVVP) is the most recent community-based, diagnostically oriented psychiatric epidemiological study among American Indian adults to be reported within the last 25 years (Beals et al., under review; Gurley et al., 2001; National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research [NCPTSD/NCAIANMHR], 1996). It was part of a congressionally mandated effort to replicate the National Vietnam Veterans Readjustment Study that had been conducted in other ethnic groups (Kulka et al., 1990).

The AIVVP found that rates of PTSD among the Northern Plains and Southwestern Vietnam veterans, respectively, were 31 percent and 27 percent, current; 57 percent and 45 percent, lifetime. These figures were significantly higher than the rates for their white, black, and Japanese American counterparts. Likewise, current and lifetime prevalence of alcohol abuse and/or dependence among the Indian veterans (more than 70% current; more than 80% lifetime) was far greater than that observed for the others, which ranged from 11 to 32 percent current and 33 to 50 percent lifetime (NCPTSD/NCAIANMHR, 1997).

There are no recent, scientifically rigorous studies that could shed light on the need for mental health care among Alaska Natives. The only systematic studies of Alaska Natives are outdated (Murphy & Hughes, 1965; Foulks & Katz, 1973; Sampath, 1974) and not based on the current DSM system of disorders. One study of Alaska Natives seen in a community mental health center indicated that substance abuse is a common reason for men (85% of those seen) and women (65% of those seen) to seek mental health care (Aoun & Gregory, 1998).

Children and Youth

Two recent studies examined the need for mental health care among American Indian youth. The Great Smoky Mountain Study assessed psychiatric disorders among 431 youth ages 9 to 13 (Costello et al., 1997). Children were defined as American Indian if they were enrolled in a recognized tribe or were first- or second-generation descendants of an enrolled member. Overall, American Indian children were found to have fairly similar rates of disorder (17%) in comparison to white children from surrounding counties (19%). Lower rates of tics (2 vs. 4%) and higher rates of substance abuse or dependence (1 vs. 0.1%) were found in American Indian children as compared with white children. The difference in substance abuse is almost totally accounted for by alcohol use among 13-year-old Indian children (Costello et al., 1997). Rates of anxiety disorders, depressive disorders, conduct disorders, and attention-deficit/hyperactivity disorder (AD/HD) were not significantly different for American Indian and white children. Yet, for white children, poverty doubled the risk of mental disorders, whereas poverty was not associated with increased risk of mental disorders among the American Indian children. Overall, these American Indian children appeared to experience rates of mental disorders similar to those for white children.

The second study reported a followup of a school-based psychiatric epidemiological study involving Northern Plains youth, 13 to 17 years of age (Beals et al., 1997). Of 109 adolescents, 29 percent received a diagnosis of at least one psychiatric disorder. Altogether, more than 15 percent of the students qualified for a single diagnosis; 13 percent met criteria for multiple diagnoses. In terms of the broad diagnostic categories, 6 percent of the sample met criteria for an anxiety disorder, 5 percent for a mood disorder (either major depressive disorder or dysthymia), 14 for one or more of the disruptive behavior disorders, and 18 percent for substance abuse disorders. Only 1 percent was diagnosed with an eating disorder. The five most common specific disorders were alcohol dependence or abuse (11%), attention- deficit/hyper-activity disorder (11%), marijuana dependence or abuse (9%), major depressive disorder (5%), and other sub-stance dependence or abuse (4%). Considerable comorbidity among disorders was observed. More than half of those with a disruptive behavior disorder also qualified for a substance use disorder. Similarly, 60 percent of those youth diagnosed with any depressive disorder had a substance use disorder as well.

Beals and colleagues compared their findings with those reported for nonminority children drawn from the population at large (Lewinsohn et al., 1993; Shaffer et al., 1996). The American Indian youth were diagnosed with fewer anxiety disorders than the nonminority children in the Shaffer sample. However, American Indian adolescents were much more likely to be diagnosed with AD/HD and substance abuse or substance dependence disorders. The rates of conduct disorder and oppositional defiant disorder were also elevated in the American Indian sample. Rates of depressive disorders were essentially equivalent. This latter finding was consistent with a study published in 1994 (Sack et al., 1994) that reported clinical depression among youth from several reservations below 1 percent, “a prevalence rate compatible with other studies in white populations, which typically varies from 1 to 3 percent” (Fleming & Offord, 1990). When compared with the Lewinsohn sample, American Indian adolescents in the study by Beals and colleagues demonstrated statistically significant higher 6-month prevalence rates than did the nonminority children for lifetime prevalence of ADHD and alcohol abuse/dependence. In addition, the American Indian youth had higher 6-month rates of simple phobias, social phobias, overanxious disorder, and oppositional defiant and conduct disorders than the nonminority children’s lifetime rates for those disorders.

At present, there are no published estimates of the rates of mental disorders among Alaska Native youth. One study of Eskimo children seen in a community mental health center in Nome, Alaska, indicated that sub-stance abuse, including alcohol and inhalant use, and previous suicide attempts are the most common types of problems for which these children receive mental health care (Aoun & Gregory, 1998). An earlier study found a high need for mental health care among Yup’ik and Cup’ik adolescents who were in boarding schools (Kleinfeld & Bloom, 1977), but current DSM diagnostic categories were not used.

Box 4–1: Charlie (age 9); Mike (father, age 29)

Charlie frequently argued with teachers and started fights with other children. Charlie’s schoolteacher recommended him for counseling because of his acting out in school.

Charlie had lived all his life with his mother and two younger siblings on their Southwestern reservation. Charlie’s father, Mike, lived in the home until Charlie was 3 years old, when he was sent to prison for attempted murder of Charlie’s mother. Mike was a chronic alcoholic who frequently battered his wife when their arguments became heated. Charlie often witnessed violence between his mother and father and was aware of the circumstances leading to his father’s imprisonment. During Mike’s incarceration, Charlie visited him in prison and maintained regular contact by mail and phone. At the time of Charlie’s referral, Mike had been out of prison for one year and had just returned home from a 30-day alcohol rehabilitation program.

Mike had been the youngest of eight children; his mother, the primary caretaker, sent Mike away to boarding school because she was unable to care for him. Mike never had contact with his father, whom he described as “an alcoholic and a womanizer.” Although Mike recognized the economic hardship his mother faced after his father left, he nonetheless felt abandoned by her and frequently wondered why she had had him in the first place.

Mike described boarding school as a constant struggle. On the weekends and holidays, Mike rarely went home; his family did not visit him. Over the years, Mike felt great sadness over his childhood loss and great anger toward his mother for her complete abandonment of him.

In addition to being physically abusive toward his wife, Mike frequently fought other men. He often felt great rage and was easily provoked

Mike was a talented artist who created pottery and woodwork designs that were derived from traditional practices within his tribe. He was a full-blooded member of his tribe. Though raised on the reservation, he spent most of his life shuttling between it and various institutions, such as boarding school, prison, and alcohol rehabilitation facilities.

In talking about his childhood, Mike was confused and incoherent, especially about his parents. He sometimes needed to leave the therapeutic setting because he had become so agitated by these feelings. Mike was preoccupied with the sense that he had been dealt a bad lot in life. This contributed to his quickness to see that others were betraying him and thus needed to be dealt with swiftly and harshly without forgiveness.

At the time of Charlie’s referral, Mike was newly committed to being a parent. Mike wanted to teach his children about his art and culture, to play sports with them, and to guide them in ways that he had not been guided. Mike acknowledged that the problems Charlie was having were not unlike the problems he had as a child. He had not appreciated the impact that the rage rooted in his own childhood experience of abandonment had on Charlie’s development. In witnessing the violence that his father let explode on his mother, Charlie had learned to fear his father and to feel powerless to protect his mother. Charlie appears to be making up for this powerlessness at home by dominating his peers through his own acts of violence. (Adapted from Christensen & Manson, 2001)

Older Adults

Although large-scale studies of mental disorders among older American Indians are lacking, Manson (1992) found that over 30 percent of older American Indian adults visiting one urban IHS outpatient medical facility reported significant depressive symptoms; this rate is higher than most published estimates of the prevalence of depression among older whites with chronic illnesses (9 to 31%) (Berkman et al., 1986). In another clinic-based investigation, nearly 20 percent of American Indian elders who received primary care reported significant psychiatric symptoms (Goldwasser & Badger, 1989), with rates increasing as a function of age. These findings are consistent with a survey of older, community-dwelling, urban Natives in Los Angeles, among whom more than 10 percent reported depression, and an additional 20 percent reported sadness and grieving (Kramer, 1991).

A recent study of 309 Great Lakes American Indian elders revealed that 18 percent of the sample scored above a traditional cutoff for depression on the Center for Epidemiology Studies Depression Scale (CES–D) (Curyto et al., 1998, 1999). However, upon further examination of that data, the factor structure of the CES–D was found to be different in this population as compared to available norms (Chapleski, Lamphere, et al., 1997). Therefore, the concern remains that the CES–D may not accurately measure depressive symptoms in this population. Nonetheless, depressive symptoms were strongly associated with impaired functioning (Chapleski, Lichtenberg, et al., 1997), which is in keeping with past findings (Baron et al., 1990) and underscores the burden posed by such distress, as well as the need for intervention (Manson & Brenneman, 1995).

Mental Health Problems

Symptoms

Although little is known about rates of psychiatric disorders among American Indians and Alaska Natives in the United States, one recent, nationally representative study looked at mental distress among a large sample of adults (Centers for Disease Control and Prevention, 1998). Overall, American Indians and Alaska Natives reported much higher rates of frequent distress—nearly 13 percent compared to nearly 9 percent in the general population. The findings of this study suggest that American Indians and Alaska Natives experience greater psychological distress than the overall population.

Somatization

The distinction between mind and body common among individuals in industrialized Western nations is not shared throughout the world (Manson & Kleinman, 1998; Manson, 2000). Many ethnic minorities do not discriminate bodily from psychic distress and may express emotional distress in somatic terms or bodily symptoms. Relatively little empirical research is available concerning this tendency among American Indians and Alaska Natives. However, a sample of 120 adult American Indians belonging to a single Northwest Coast tribe was screened using the Center for Epidemiologic Studies Depression Scale, which includes both psychological and somatic symptoms. Analyses showed that somatic complaints and emotional distress were not well differentiated from each other in this population (Somervell et al., 1993). Other inquiries into the psychometric properties of the CES–D and other measures of depressive symptoms among American Indians have yielded similar findings, providing some evidence of the lack of such distinctions within this population (Ackerson et al., 1990; Manson et al., 1990).

Culture-Bound Syndromes

A large body of ethnographic work reveals that some American Indians and Alaska Natives, who may express emotional distress in ways that are inconsistent with the diagnostic categories of the DSM, may conceptualize mental health differently. Many unique expressions of distress shown by American Indians and Alaska Natives have been described (Trimble et al., 1984; Manson et al., 1985; Manson 1994; Nelson & Manson, 2000). Prominent examples include ghost sickness and heart-break syndrome (Manson et al., 1985). The question becomes how to elicit, understand, and incorporate such expressions of distress and suffering within the assessment and treatment process of the DSM–IV.

Suicide

Given the lack of information about rates of mental disorders among American Indian and Alaska Native populations, the prevalence of suicide often serves as an important indicator of need. The Surgeon General’s 1999 Call to Action to Prevent Suicide indicates that from 1979 to 1992, the suicide rate for this ethnic minority group was 1.5 times the national rate. The suicide rate is particularly high among young Native American males ages 15 to 24. Accounting for 64 percent of all suicides by American Indians and Alaska Natives, the suicide rate of this group is 2 to 3 times higher than the general U.S. rate (May, 1990; Kettle & Bixler, 1991; Mock et al., 1996). In another survey of American Indian adolescents (n = 13,000), 22 percent of females and 12 percent of males reported having attempted suicide at some time; 67 per-cent who had made an attempt had done so within the past year (Blum et al., 1992). Furthermore, an analysis of Bureau of Vital Statistics death certificate data from 1979 to 1993 found that “Alaska Native males had one of the highest documented suicide rates in the world” (1997). Alaska Natives, in general, were more likely to commit suicide than non-Natives living in Alaska (Gessner, 1997). It is important to note that violent deaths (unintentional injuries, homicide, and suicide) account for 75 percent of all mortality in the second decade of life for American Indians and Alaska Natives (Resnick et al., 1997).

High-Need Populations

American Indians and Alaska Natives are the most impoverished ethnic minority group in the United States. Although no causal links have yet been demonstrated, there is good reason to suspect that the history of oppression, discrimination, and removal from traditional lands experienced by Native people has contributed to their current lack of educational and economic opportunities and their significant representation among populations with high need for mental health care.

Individuals Who Are Homeless

American Indians and Alaska Natives are overrepresented among people who are homeless. Although they comprise less than 1 percent of the general population, American Indians and Alaska Natives constitute 8 per-cent of the U.S. homeless population (U.S. Census Bureau, 1999a). It is not clear that homeless American Indians and Alaska Natives are at greater risk of mental disorder than their non-Native counterparts. In one study, American Indian veterans who were homeless had fewer psychiatric diagnoses than did white veterans who were homeless (Kasprow & Rosenheck, 1998), although these differences were relatively small. Nevertheless, because there are more individuals with mental disorders among the homeless population than among the general population (Koegel et al., 1988), this finding likely points to a substantial number of Native people with a high need for mental health care.

Individuals Who Are Incarcerated

In 1997, an estimated 4 percent of racially identified American Indian and Alaska Native adults were under the care, custody, or control of the criminal justice system. Also, 16,000 adults in this group were held in local jails (Bureau of Justice Statistics, 1999). Although research specific to rates of mental disorders among American Indian and Alaska Native adults in jails is not available, a recent study has evaluated disorders among incarcerated adolescents. Rates of mental disorders among those held in a Northern Plains reservation juvenile detention facility were examined (Duclos et al., 1998). Among the 150 youth evaluated, nearly half (49%) had at least one alcohol, drug, or mental health disorder. The most common problems detected were substance abuse, conduct disorder, and depression.

These rates were higher than those found in Indian adolescents in the community, indicating that incarcerated American Indians are likely to be at high need for mental health and substance abuse interventions.

Individuals with Alcohol and Drug Problems

Actual rates of alcohol abuse among American Indian adults are difficult to estimate, yet indirect evidence suggests that a substantial proportion of this population suffers from this problem. For example, the estimated rate of alcohol-related deaths for Indian men is 27 percent and for Indian women 13 percent (May & Moran, 1995). Rates appear to vary widely among different tribes. Although the topic of substance abuse is beyond the scope of this Supplement, alcohol problems and mental disorders often occur together in American Indian and Alaska Native populations (Westermeyer, 1982; Whittaker, 1982; Westermeyer & Peake, 1983; Kinzie et al., 1992; Beals et al., 2001). A recent study, which sought to understand the link between alcohol problems and psychiatric disorders in American Indians, included over 600 members of three large families (Robin et al., 1997a). More than 70 percent qualified for a lifetime diagnosis of alcohol disorders. Among both men and women, those who were alcohol-dependent were also more likely to have psychiatric disorders, as were those who engaged in binge-drinking behavior. This finding underscores the likelihood that American Indians with alcohol disorders are at high risk for concomitant mental health problems.

Given the high rates of alcohol abuse among some American Indians and Alaska Natives, fetal alcohol syndrome is an important influence on mental health needs (May et al., 1983). The Centers for Disease Control and Prevention (1998) monitored the rate of fetal alcohol syndrome (FAS), identifying cases based on hospital discharge diagnoses collected from more than 1,500 hospitals across the United States between 1980 and 1986. The overall rate of FAS was 2.97 per 1,000 for Native Americans, 0.6 per 1,000 for African Americans, 0.09 for Caucasians, 0.08 for Hispanics, and 0.03 for Asians (Chavez et al., 1988). As might be expected given the fact that physicians often do not identify this disease, these rates are much lower than those found in clinic-based investigations (Stratton et al., 1996). Fetal alcohol syndrome now is recognized as the leading known cause of mental retardation in the United States (Streissguth et al., 1991), surpassing Down’s syndrome and spina bifida. Fetal alcohol syndrome is not just a childhood disorder; predictable long-term progression of the disorder into adulthood includes maladaptive behaviors such as poor judgment, distractibility, and difficulty perceiving social cues. Consequently, American Indians and Alaska Natives with fetal alcohol syndrome are likely to have high need for intervention to facilitate the management of their disabilities.

Drinking by American Indian youth has been more thoroughly studied than drinking by American Indian adults. Ongoing school-based surveys have shown that, although about the same proportion of Indian and non-Indian youth in grades 7 to 12 have tried alcohol, Indian youth who drink appear to drink more heavily than do youth of other ethnicities (Plunkett & Mitchell, 2000; Novins et al., under review). They also experience more negative social consequences from their drinking than do their non-Indian counterparts (Oetting et al., 1989; Mitchell et al., 1995). Although drinking and mental disorders may be less linked for youth than for adults, those adolescents with serious drinking problems are likely to be at risk for mental health problems as well (Beals et al., 2001).

Individuals Exposed to Trauma

Lower socioeconomic status is associated with an increased likelihood of experiencing undesirable life events (McLeod & Kessler, 1990). As a result of lower socioeconomic status, American Indians and Alaska Natives are also more likely to be exposed to trauma than members of more economically advantaged groups. Exposure to trauma is related to the development of sub-sequent mental disorders in general and of post-traumatic stress disorder (PTSD) in particular (Kessler et al., 1995). Recent evidence suggests that American Indians may be at high risk for exposure to trauma.

An investigation of Northern Plains youth ages 8 to 11 found that 61 percent of them had been exposed to some kind of traumatic event. These children were reported to have more trauma-related symptoms, but not substantially higher rates of diagnosable PTSD (3%) (Jones et. al., 1997). According to the Bureau of Justice Statistics (1999), the rate of violent victimization of American Indians is more than twice as high as the national average. Indeed, the data regarding reported child abuse in Native communities indicate that this phenomenon has increased 18 percent in the last 10 years (Bureau of Justice Statistics, 1999). Another study noted a high prevalence of trauma exposure (e.g., car accidents, deaths, shootings, beatings) and PTSD within those in the family study mentioned above (Robin et al., 1997c). Of those studied, 82 percent had been exposed to one traumatic event, and the prevalence of PTSD was 22 percent. Because American Indians probably are similar to non-Indians in their likelihood of developing PTSD after a traumatic exposure (Kessler et al., 1995), the substantially higher prevalence of the disorder (22% for AI/AN vs. 8% in the general community) does not signal greater vulnerability to PTSD, but rather higher rates of traumatic exposure.

Maltreatment and neglect have been shown to be relatively common among older urban American Indian and Alaska Native patients in primary care. A chart review of 550 Native adults 50 years of age or older seen at one of the country’s largest, most comprehensive, urban Indian health programs during one calendar year revealed that 10 percent met criteria for definite and probable physical abuse or neglect (Buchwald et al., 2000). After control-ling for other factors in a logistic regression model, patient age, female gender, alcohol abuse, domestic violence, and current depression remained significant correlates of physical abuse or neglect of these Native elders.

The previously mentioned American Indian Vietnam Veterans Project (AIVVP) replicated the National Vietnam Veterans Readjustment Study that examined psychiatric disorders among African American, Latino, and white veterans (Kulka et al., 1990). Between 1992 and 1995, researchers evaluated random samples of Vietnam combat veterans drawn from three Northern Plains reservations (n = 305) and one Southwest reservation (n = 316). Approximately one-third of the Northern Plains (31%) and Southwestern (27%) American Indian participants had PTSD at the time of the study. Approximately half had experienced the disorder in their lifetimes (57% and 45%, respectively). This rate is far in excess of rates of current PTSD for white veterans (14%) and for black veterans (21%) (Kulka et al., 1990). The excess rates, however, were largely attributable to the fact that American Indian veterans had been exposed to more combat-related traumas than their non-Indian peers (National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research, 1996; Beals et al., under review).

Box 4–2: John : Vietnam Combat Veteran (age 45)

John is a 45-year-old, full-blood Indian, who is married and has 7 children. The family lives in a small, rural community on a large reservation in Arizona. John served as a Marine Corps infantry squad leader in Vietnam during 1968–1969. He most recently was treated through a VA medical program, where he participates in a post-traumatic stress disorder (PTSD) support group. John suffers from alcoholism, which began soon after his initial patrols in Vietnam. These involved heavy combat and, ultimately, physical injury. He exhibits the hallmark symptoms of PTSD, including flashbacks, nightmares, intrusive thoughts on an almost daily basis, marked hypervigilance, irritability, and avoidant behavior.

Some 10 years after his return from Vietnam, John began cycling through several periods of treatment for his alcoholism in tribal residential programs. It wasn’t until one month after he began treatment for his alcoholism at a local VA facility that a provisional diagnosis of PTSD was made. Upon completing that treatment, he transferred to an inpatient unit specializing in combat-related trauma. John left the unit against medical advice, sober but still experiencing significant symptoms.

John speaks and understands English well; he also is fluent in his native language, which is spoken in his home. John is the descendant of a family of traditional healers. Consequently, the community expected him to assume a leadership role in its cultural and spiritual life. However, boarding school interrupted his early participation in important aspects of local ceremonial life. His participation was further delayed by military service and then fore-stalled by his alcoholism. During boarding school, John was frequently harassed by non-Indian staff for speaking his native language, for wearing his hair long, and for running away. Afraid of similar ridicule while in the service, he seldom shared his personal background with fellow infantrymen. Yet John was the target of racism, from being selected to act as point on patrol because he was an Indian to being called “Chief” and “blanket ass.”

Until recently, tribal members had never heard of PTSD, but now frequently refer to it as the “wounded spirit.” His community has long recognized the consequences of being a warrior, and indeed, a ceremony has evolved over many generations to prevent as well as treat the underlying causes of these symptoms. Within this tribal worldview, combat-related trauma upsets the balance that underpins someone’s personal, physical, mental, emotional, and spiritual health. The events in John’s life (the Vietnam war, his father’s death, and his impairment due to PTSD and alcoholism) conspired to prevent his participation in this and other tribal ceremonies.

John attends a VA-sponsored support group, comprised of all Indian Vietnam veterans, which serves as an important substitute for the circle of “Indian drinking buddies” from whom he eventually separated as part of his successful alcohol treatment. John reports having left the VA’s larger PTSD inpatient program because of his discomfort with its non-Native styles of disclosure and expectations regarding personal reflection. Through the VA’s Indian support group, he joined a local gourd society that honors warriors and dances prominently at pow-wows. His sobriety has been aided by involvement in the Native American Church, with its reinforcement of his decision to remain sober and its support for positive life changes.

Though John has a great deal of work ahead of him, he feels that he is now ready to participate in the tribe’s major ceremonial intended to bless and purify its warriors. His family, once alienated but now reunited, is busily preparing for that event. (Adapted from Manson, 1996).

Children in Foster Care

Studies have consistently indicated that children who are removed from their homes are at increased risk for mental health problems (e.g., Courtney & Barth, 1996), as well as for serious subsequent adult problems such as homelessness (Koegel et al., 1995). By the mid-1970s, many American Indian children were experiencing out-of-home placements. In Oklahoma, four times as many Indian children were either adopted or in foster care as investigation that led to the passage of the act concluded non-Indian children. In New Mexico, twice as many that “a pattern of discrimination against American Indian children were in foster care than any other minor-Indians is evident in the area of child welfare, and it is ity group. Estimates suggest that as many as 25 to 30 the responsibility of Congress to take whatever action is percent of American Indian children have been removed within its power to see that Indian communities and their from their families (Cross, et al., 2000). As a result, families are not destroyed” (Fischler, 1985). Congress passed the Indian Child Welfare Act in 1978 to Accordingly, in 1999, the number of American Indian protect American Indian children. The Congressional and Alaska Native children in foster care had decreased to 1 percent of all children in foster care in the United States (DHHS, 1999). Yet the mental health consequences for the children, now adults, who were placed out of their homes, especially those placed in non-Indian homes, during this lengthy period of mass cultural dislocation is not known (Nelson et al., 1996; Roll, 1998).