Counseling Alaskan Natives and American Indians

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox I'd like to welcome everybody to today's presentation. We're going to be talking about behavioral health services for American Indians and Alaskan Natives and this is based on SAMHSA tip 61 that I showed you at the beginning of class. You can download the entire tip, which is a treatment improvement protocol from SAMHSA for free. It's a PDF. It's about 240 pages, but it provides a ton of information. I am hitting the highlights as they pertain to counseling practice more than the background information that is really, really is important for you to have if you're going to be working with people from a different culture. Anyway, there are a lot of there is a lot of information in the treatment improvement protocol on historical issues that are still affecting people who are Alaskan Natives or American Indians today. So if you do work with this population, I strongly recommend giving the tip a read. It's not a hard read, it's not like reading a journal article, and it does provide a ton of additional information. What I want you to do is improve your understanding of American Indian and Alaska Native behavioral health. Understand the importance of cultural awareness, cultural identity, and culture specific knowledge when working with clients from diverse backgrounds. We're going to explore the role of Native culture in health beliefs, health seeking behavior and healing practices, prevention and treatment interventions based on culturally adapted evidence based practices. And we're really just going to hit the highlights on those and methods for achieving program level cultural responsiveness. I'm going to start out with a couple of slides and I didn't know what else to call them besides factoids. 22% of American Indians and Alaskan Natives live on reservations. So the majority of this population does not live on reservations and they may be using services that are in the general public, if you will. 60% live in urban areas. If you are in an urban area, be aware, especially if you are in an urban area that is not terribly far from a reservation. You may have people from whose family may live on the reservation or who don't live there anymore, but they moved into the urban area for employment. It's interesting to note that there are more than 200 tribes in Alaska and although there are similarities, there are also significant differences between tribes. So you don't want to just say, okay, all Alaskan Natives or all American Indians believe or do this. It's important to recognize the nuances between the different tribes. The term Eskimo is considered derogatory by many. It's important to be aware of your language. Health solutions with this population often come from within the community. Using local models now, they recognize that certain issues such as substance abuse may be influenced or brought into the community by the white man. However, the health solutions that we're going to be talking about really need to come from within the community in order to help the community as its whole become healthier. 25% of American Indians and Alaskan Natives live in poverty in comparison with 13% of the general population. Okay, so double the number. That's a big number. And fewer than 50% of American Indian or Alaskan Native women who experience violence report it. And of those, only 10 to 40% of cases are ever even prosecuted. We do need to do a lot with advocacy in an education. Education protects against substance abuse, depression, suicidality, and other behavioral health problems for American Indians and Alaskan Natives as well as other populations. This is not new news yet. This population is less likely than the general population to graduate. And the presentation I did last year on providing culturally responsive services to Alaskan Natives and American Indians talked about some of the reasons for that. And part of the reason for that is that people from these cultures in general, but not, you know, there are nuances, tend to respect an oral tradition and tend to be more auditory learners. And the way we teach in mainstream school is very book oriented. So you see a significant decrease in grades and self esteem and a significant increase in mood disorders and substance use issues starting right around eighth grade for a lot of people in this population. American Indians and Alaskan Natives typically define family as extending beyond the nuclear family and sometimes not even biologically related. About half of the households include members of the extended family, and a quarter include people who are not directly related at all. You do have a lot of community within these cultures. About 30% of American Indian and Alaskan Native families are headed by single mothers, and grandparents often help or raise the children. So those things are interesting to know. And I'm not sure if the 30% is due to divorce or low marriage rates, but the statistic was shocking to me. Not all Native cultures are the same. We need to remember that, and I'm going to keep saying it. Similarities do exist, but each nation has its own beliefs and traditions. American Indians and Alaskan Natives are less likely to drink than white Americans. Well, that's a good point. However, those who do drink are more likely to binge drink and to have a higher rate of past year alcohol use disorder than other racial and ethnic groups. So the fact that they are less likely to drink is good, but when they do start drinking, it tends to be a lot more intense. Alaskan Natives and American Indians experience anxiety disorders at a higher rate than other Americans. If you're seeing this population in your clinic, be aware of that. Don't assume that you're going to see anxiety disorders, but be aware that anxiety may be out there. And this is one of those things we'll get to in a few minutes that we can start targeting. Because in these communities, often prevention and treatment are not seen as separate things. They're seen as along a continuum. We can go in and advocate for prevention activities to address anxiety disorders and substance use and those sorts of things. Native youth have a much higher suicide rate than the youth or adults of other races and is actually more than double than that for the U.S. population. And suicide attempts among young men ages 15 to 24 account for nearly 40% of all suicide deaths among Natives. This is another thing that we need to know in terms of prevention. If you're targeting a prevention group, we really need to hone in on and work with the community to identify what are some of the triggers for this particular population. That's a very specific population. 15 ages 15 to 24 males. Likely reasons for today's high rates of substance abuse, suicide and domestic abuse among American Indians and Alaskan Natives are that their communities are exposed to a greater degree to some of the same risk factors that are predictors of problems for everyone, including poverty, unemployment, trauma, including historical trauma, and a loss of cultural traditions. We're seeing that, you know, where people in who are not in this population may be exposed to these risk factors, you know, at a rate of 30%, if you will, then we see these cultures. The American Indians and Alaskan Natives are exposed to these issues at more of a 40, 50, 60% rate. So they're exposed to the same things, but more often to a greater intensity. Maintaining ties to one's culture can help to prevent and treat substance use and mental health disorders in this population. But we don't want to assume that someone who comes into our clinic who happens to be American Indian or Alaskan Native embraces their culture. They may be fully acculturated to mainstream or the majority culture, and they may not have a desire to embrace their cultural heritage. We do want to be sensitive. Among many Native American, substance abuse and mental disorders are not defined as diseases or character flaws. Well, that's A good thing. They are seen as a symptom of imbalance in the individual's relationship with the world. We're going to talk when we get to the treatment section, a lot about balance and helping them rebalance their life and their connections with their family, with their community, with their environment in order to find a sense of contentment and wholeness. Let's talk for a minute about historical trauma. One of the causes of people's imbalances with the world and their community stems from widespread abuses and injustices experienced by American Indians and Alaskan Natives, including loss of their communities, loss of life partly when they were fighting for their communities, loss of freedom, loss of land, loss of self determination, loss of traditional cultural and religious practices. One thing the book talked about, and I said earlier that there's a lot of historical information in the tip that's really important to read through to understand where this historical trauma is coming from. And just too much in there to squeeze into this hour. But that stuff is really important to review if you're working with people from these cultures. For example, practicing many cultural traditions was illegal from 1878 until 1978. That's 100 stinking years it was illegal to practice those cultural traditions. Now think about some of your cultural traditions. What would happen if it was illegal for you to practice, if it was illegal for you to go to church, if it was illegal for you to celebrate holidays, if you know, you see where I'm going, What would that do to your sense of identity and community? There's also a loss of native languages and the removal of children from their families. There was a long period there where children were separated from their families and sent to boarding schools whether they wanted to or not. Historical trauma has been defined as the cumulative emotional and psychological wounding across generations. We're going to talk about how that happens in a minute, including the lifespan which emanates from massive group trauma. So this whole group of people is exposed to oppression and violence and you know, you can list those things off. What does that do to that group of people? It's critical to incorporate the role of historical trauma and assessments in developing treatment plans and, and in implementing healing strategies. We're going to talk a lot about how it's important to involve the community in the healing process. Because if one individual in the community is out of balance, it affects the community. And likewise, if the community is out of balance, it affects the individual. Well, historical trauma affects the community for certain, which means it's going to affect individuals within the community. We want to Understand what the impact of that is for that particular person in their particular community. Historical trauma may be different from other trauma in that the distress resulting from the trauma is collective rather than individual. Not only do you experience trauma, but you're seeing your neighbor experience trauma and your grandparents experience trauma. You're seeing it all around. And it seems like everybody in your culture is being exposed to this trauma. And the cause of the trauma often comes from people outside the community impacted by it. Trauma can affect future generations physically by raising the risk of certain diseases. When we experience trauma, it puts a huge demand and stress on our body. So it can raise the risk of lots of stress related diseases. Socially, by increasing child abuse and domestic violence. You have people that are enduring this trauma, they're stressed out, they're, you know, trying to survive. They tend to have less patience, if you will. So we do see in people who are impoverished and struggling and experiencing trauma, we do see an increase in child abuse and domestic violence. Psychologically, trauma can cause depression or ptsd. Well, that's not new news. And spiritually, it can affect future generations when the traumatized individuals lose hope. We pass hope on to the generations. We pass hope on to our kids. We want them to see the bright future in front of them. And if we can't see a bright future, we can't communicate that bright future if we don't believe there's any hope. Historical trauma can be transmitted across the generations through its effect on parenting. And Braveheart did a study, and that's her last name, in 1999, and she suggests that trauma is experienced by parents and can disrupt traditional parenting practices. Well, that's not surprising. You experience trauma, you're under stress at best. When you're under stress, it's harder to have secure attachments and connect emotionally and physically with your children. Okay, that makes sense. When you're experiencing trauma, if you develop ptsd, what are some of the symptoms of ptsd? Hypervigilance, withdrawal, emotional numbing. If you have some of those going on, then it may be more difficult to parent your children. It may be more difficult to be emotionally and physically present and help guide them and help them learn what is safe and what isn't safe. Because in a hyper vigilant world, there's a lot that seems unsafe. It can affect parenting by increasing substance abuse, mental health and physical health issues. Think about your aces, your adverse childhood experiences. If there is someone in the household with a mental health or substance abuse issue, then that's considered a adverse childhood experience. Well, let's take that here, if we have people experiencing historical trauma or who've experienced trauma, then it can cause disruptions in attachment and lots of, and promote mental health issues in future generations because of those adverse childhood experiences. So you have Great Grandma experienced a trauma. Great Grandma has ptsd, depression, stress related illnesses. She's doing her best to parent her children, if the children are even still left in the home. And we'll talk about that in a few minutes. But assuming the children are still there, doing her best to parent. But we know that that adverse childhood experience for those kids can promote depression and substance abuse and potentially historical trauma in them. So then they grow up to be parents and they're still experiencing mental health and physical health disorders. So now they're the parent in the household that is causing the adverse childhood experiences. And you see how this cycle just perpetuates itself unless, unless we can break it. Trauma can affect trust and intimacy and the ability to form a healthy bond with one's children. Especially in some of these cultures where they were routinely having their children ripped out of their arms, so to speak, and put in boarding schools. They didn't have a choice. They never developed. There's whole generations of people in this particular culture who never had the opportunity to parent, to learn how to parent. So then, and the children were in boarding schools and they, you know, maybe developed some sense of parenting from the headmaster, if you will, but they were never parented. So then when they have kids, how are they supposed to know what they're supposed to do? I mean, even those of us who are raised in your traditional households have kids and we're like, oh, you know, I wish they came with an instruction manual. We need to recognize this, some of the skills needed to be parents and to help people learn how to deal with their emotional and physical health issues. Some people didn't develop. And trauma can cause secondary victimization when parents tell stories of historical events or their own experiences and children are hearing this and they're going, oh my gosh, that's horrible. The world is not safe. Those people are bad people. And remember, children think dichotomously. They don't think, okay, well, there was this group back in 1960, something that, no, they're thinking dichotomously, them versus us. And the more people experience trauma regardless of their age, a lot of times the more we see that dichotomous thinking and happening because that's how people try to figure out who is safe. Children also witness and to some extent internalize their parents reactions in times of stress when the parents trauma reactions are triggered. If a parent experiences a stress reaction, Grandma, you know, experienced horrible abuse at the hands of, you know, the legal system, for example. And then the parent, grandma had a child and the child saw this and is just traumatized and overwhelmed. Well, then when something similar might happen, or the now parent might see what's going on or have a trigger that reminds her of that past, then it's going to create bring up that trauma reaction, same thing we see in ptsd. And the children are going to see that, and the children are going to think, oh, my gosh, that's not safe. Look at mom's reaction, look at dad's reaction. That's not safe. So then they start having all of these folders, if you will, in their schema of safe and not safe. Historical trauma is intended to help the provider find ways of discussing current trauma and emotional or behavioral problems in a context that is not stigmatizing. It's not, you did this or what did you do to bring this on. It's your culture experienced this horrible thing. So let's talk about how to help your community heal. It presents trauma as a collective experience and one that communities can work together to overcome. And Frederick points out that the Wellbriety movement and White Bison have made great strides with some issues in trying to help break this cycle and address some of the historical trauma. So if you want to look up Wellbriety and also Braveheart has a lot of writings out there. You just have to Google her name. You can find a lot. Oops. So the cycle of historical trauma. There's a history of trauma and historical trauma. Then the traumatic stress reactions, including grief and other strong emotional and physical reactions. When there's a trauma trigger, you see something, it reminds you flashbacks that causes an increased risk of substance abuse and dependence and an increased vulnerability to suicidal and mental health disorders. So now they're traumatized and they're at greater risk for mental health disorders, which leads to an increased risk of experiencing other traumas in their life. All right, so we're going to move on to counseling now. What you're probably here to really hear a lot about, what I wanted you to understand is some of the historical stuff that is important for you as clinicians to understand when starting to work with this population, so you might understand some of the nuances as a provider in an initial meeting, it is important to promote, support, house, and help facilitate the development of prevention activities in Native communities. So if you're going to plop your shingle out or your agency is going to open a. A facility in a place where there is a population of people who are Alaskan, Native or American Indian. It is really important to start reaching out to those community leaders and going, okay, how can I help your community break this cycle and become healthier? There's nothing traumatizing about that. It's us saying, we recognize that we may have contributed some of this. How can we help your community be healthier? So everyone in your community can be healthy. When meeting somebody for the first time, and generally every time, but when meeting them for the first time, give your name and job title and explain briefly about something about yourself, what you're doing and why. Tell them why they're there for the assessment. Tell them a little bit about yourself. You need to establish some sort of rapport. You don't want to just take them in and plop them down and go, okay, I'm Dr. So and so, and we're going to be talking for the next, you know, hour and a half, and I'm going to be asking you, you know, all these details about your life. That's not how it goes. You need to establish some rapport. Take your cue from clients when it comes to offering a handshake and expect that at first it may be light as a sign of politeness and respect. Don't take that as withdrawn or anything. It's a sign of respect. And initially, keep your eye contact brief until you observe the habits of your clients. Some clients will make a lot more direct eye contact. Again, out of respect, some clients may not make much direct eye contact. You don't want to assume that poor eye contact is a sign of some mood disorder. And in this population, confidentiality is huge, especially if you're working in an area that has a large population of Alaskan natives or American Indians, that you may have people employed at your agency who are known to your clients, and that may make them feel uncomfortable. We need to be able to assure them of confidentiality and talk with the community leaders and talk with the people in the community about how. What can we do that would help you feel more comfortable coming to the clinic? What can we do to help respect your confidentiality during the assessment? Explore and assess the client's cultural identity. See where they are on that continuum from embracing their native culture to being bicultural to being fully acculturated into the dominant culture. Get an idea. Talk with clients. And this is not new stuff, but it's important to reiterate it. Ask them about what their perspective is on what caused the problem and what prompted them to enter treatment? Are they being forced in? Is there something that they want to work on? What thoughts do they have about how to return to a more balanced state? And we're going to talk repeatedly about balance and that's one of those key words that we can use in order to work with people. Because it doesn't matter, you know, if you're working with somebody who's not Native American or I'm sorry, Alaskan Native or American Indian. All of us need balance. So using the word balanced state is not something that necessarily is unique to this population. We want to assess what clients already know about their problem and what they've tried to do. That whole solution focused stuff. How do they see the problem? How does it affect different aspect of their lives? What do they think will help them heal? And what does successful healing look like for them? Not everybody has the same goals of recovery. One thing that is important to recognize in this population is that sometimes they may believe that their distress is put on them because either they have broken a rule or a more of the culture or someone in their family has. So it is their responsibility to bear that burden. Right now we don't necessarily want to take. Well, we don't want to take that away from them. We want to help them figure out how to become more balanced. And even if they feel like they have to tote that burden. Identify treatment goals that are important for your clients and incorporate cultural activities and or Native healers in treatment if the client wishes. A lot of clients may want to incorporate Native healers and Native healing activities. I will put this caution caveat out there that there are a lot of really amazing practices that American Indians and Alaskan Natives use. However, some of them can be very dangerous if they're not done by a very skilled person. You don't want to take it upon yourself to start having your own sweat lodge, for example. That's a no go. You want to make sure that you leave it in the hands of the the experts. Creating culturally responsive services requires the participation of the Native community, including formal and informal leaders, councils, clients, potential clients, and client families. We don't want to just go to the leaders. We also want to talk to the families that are in that community. Avoiding community participation represents an example of paternalism in which providers assume that they inherently know what's best for their program, for the client, for the staff, for the community. And that's just not so. You know, if you have never walked a mile in their shoes, lived in their community, you have an idea about what your utopia looks like, but not necessarily what their utopia looks like or the best way to get there. American Indian and Alaskan Native beliefs revolve around the value of connectedness and the importance of relationships. So if we don't build relationships or demonstrate interests in their community, they may be less accepting of our services offered. Now, this gets a little uncomfortable for some of us sometimes because we're taught in graduate school and repeatedly in our ethics classes about dual relationships, and you shouldn't do stuff with your clients, etc. Well, you're not doing, you're not going on a date with your clients, but you may be participating in community festivals or attending community festivals, and that is a show of involvement and connectedness. Culturally responsive services will likely provide clients with a greater sense of safety and support. The belief that the culture is essential to healing. If we incorporate these, they're saying, okay, you know, this person believes that this might be a useful avenue to pursue healing. And treatment approaches need to be inclusive of all aspects of life, incorporating the spiritual, emotional, physical, social, behavioral, and cognitive. Again, from a biopsychosocial perspective, the. That's not really different except for the spiritual component. A lot of clinicians are not comfortable going there, so to speak. So it's really important to learn more about the spirituality of your clients. Healing can come from reconnecting to strengths inherent in traditional teaching practices and beliefs and begin to walk in balance with their community and with their environment, helping them feel that sense of grounding, if you will. The division between physical and behavioral health is not one that's typically recognized because one aspect of health is believed to affect the other. Well, that's what we've been talking about for weeks here. You know, if your physical health, if your body machine is not working efficiently, then you're going to have a hard time focusing and having good moods and being patient and all that stuff. Likewise, if you are depressed, angry, experiencing ptsd, yada, yada, that is going to have a direct impact on your physical health. Health problem that affects one person will have effects on the family, community, and tribe in this culture. It is important to recognize that. And that person may have treatment issues revolving around how their current imbalance is affecting not only their family, but their community and their tribe. As I said earlier, prevention and treatment are seen as part of the same process, and illness is the reflection of imbalance or disharmony. So from a prevention standpoint, we can help people maintain balance and harmony. And part of treatment is bringing people back into balance and harmony. Healing the community can positively affect the individual health and that the process of healing may need to occur at the community level to be effective for the individual. This is not all that surprising. Think about when you're working with an identified patient and they may be doing really well, but then they go home and their home life is completely dysfunctional, and it sort of undoes all the good work that they've been doing in counseling. And every time they go home, it undoes it. So if there's imbalance in the community, in the tribe, in the family system, it's going to affect the individual. In order to benefit the individual and help them feel more balanced, we need to help that environment also become healthier. Totally makes sense. An illness may occur because of an individual or relative has broken some cultural or natural law recently in the past or in a previous generation. Because of this, a person may be held at least in part responsible for developing an illness. And the individual who has the illness may see it as his or her responsibility to bear those symptoms. I said that earlier, but I thought it was important to repeat it. Too often we see as a goal for treatment the complete amelioration of the distress. And for people in this culture, that might not be actually the treatment goal. They may be more in the acceptance and commitment therapy realm of accepting that pain is a part of life and they can still live a rich and meaningful life. An illness can also be personified in the sense that it has a spirit. And that spirit may need to be addressed as part of the healing. And they really didn't talk about how to address the spirit in the healing. And that would be something you would want to consult with traditional healers in that particular culture. Now, remember, there's over 200 tribes. You want to make sure that you're consulting with the right healers and understanding. When Christina asked, when you're working with an individual, how do you improve the person's environment? And that goes back to when you ask the person about whether their family is going to be. How much their family is going to be involved, or we may not have even gotten to that yet. And if the person is opposed to having their family or their community involved, then, okay, you know, we need to respect that. But if they are open to having their family and or community involved, then that's how we start treating it. They are the, quote, identified patient. We're seeing them individually, but we may also be working or referring, if you will, to the. To the traditional healer who is going to be also working with them and working with Their family and their community may be incorporating some traditional healing practices. Traditional practices often increase social support, thereby improving health. Most of your traditional practices involve circles or congregations of people, which encourages balance within the community. Healing rituals improve participants coping abilities and quality of life. Traditional healers have stories that guide individuals on how to handle various problems. One thing that is important in this culture usually is not giving too much advice. It's important for the person to be able to find their own direction. A lot of traditional healers will propose a story, if you will, and then let the person sit with that story and take that advice. Not advice, take that information about whatever happened in the story and figure out how to apply it to their current situation. We want to be advocates and consultants. We don't want to be overly directive. Traditional healing helps individuals transcend their experiences by identifying the meaning and purpose of those experiences within the context of the community, including their environment. This is something we can talk about in counseling. If somebody is experiencing clinical depression, let's identify the meaning and the purpose of those depressive symptoms. Remember, it can be personified to a certain extent. So we need to understand that. We need to understand where that depression, why those symptoms are present for that person in their mind. And what is the purpose of those symptoms? Is it a warning sign that something's out of balance, that there's disharmony? And what are those symptoms telling you that you want you need to do? Some traditional healing rituals alter participants consciousness, which in turn can produce a spiritual transformation that affects overall health. And these are some of those rituals. I was saying leave to the traditional healers. Don't go off half cocked and go. That sounds like an interesting idea. No, you can kill people doing this, so leave it to people who are experts. They literally have generations of training. Traditional healing practices can include offering tobacco with one's prayers, which is often done in a group. Burning herbs or smudging for purification. Participating in a talking circle where an object is passed around, allowing everyone to express feelings and thoughts. You see where we've got a lot of community here. Giving herbal medicines. Performing a sweat lodge or spirit lodge to experience purification, prayer and healing. Performing tribal dances, chanting and singing in groups, which actually can go on for days. It's not just something you do for an hour. Creating medicine bags that hold a specific meaning for the owner. Engaging in other traditional ways, such as carving or tanning hides. Why? Because if they get back to basics, they get back to traditional practices. Then they can be more at one with the community and the environment. And using humor to Address and survive many difficult situations. Don't be surprised if you're working with somebody who is American Indian or Alaskan Native who uses humor sometimes in the sessions because they tend to be a pretty jovial group of people, according to the book, and do use humor a lot because humor has helped them get through challenging situations. So let's talk about some commonalities. Since there are so many different tribes and so many different nations, there is no one book or one. You know, here's a suggestion for how to deal with this, this particular group right here. You need to ask that person. And you also don't want to lump American Indians and Alaska Natives as two separate groups and go, okay, I just need to know those two things. No, you need to know the nuances of the different tribes within. Do be aware of that. If you live in an area where you have populations of American Indians or Alaskan Natives, there probably is some assistance. And if not, you can call the SAMHSA Tribal Information Center, I think, and get information about. You know who to go to in order to get assistance or consultation in working with clients in your community. American Indians and Alaskan Natives believe that they are only one part of creation. They're dependent on nature and meant to live in harmony with all things. We talk a lot about mindfulness. This kind of goes down to mindfulness, feeling our sense of connectedness to people, things and the energies that we put out. Native Americans believe in the importance of balance and harmony internally for the individual. So you need to have balance in yourself. Otherwise you're going to feel stressed out, pulled six different directions, whatever. Socially, among people, there needs to be balanced. There needs to be give and take and share and care and naturally in relationships with animals and the rest of creation. We need to recognize, or Native Americans recognize their impact if they kill a bison or if they kill a deer or what have you, what impact that has on the universe. Community norms and values play an important role in all aspects of life for American Indians and Alaskan Natives, including treatment and recovery. Involving family and community in the development of treatment programs. Not treatment plans, but treatment programs. So if you're going to open an IOP program, for example, involve family and community in it so you understand what works in that local culture. That's one of the most effective tools to make sure that the services you're providing are spot on. It's important to ask about their families and their willingness to be involved in treatment if the person is not willing to have their family involved in treatment. Like I said earlier, that is their choice. Do remember though that shame is a strong factor preventing service access for a lot of people because accessing services means admitting an imbalance and it can mean for some admitting that they've done something for which they're being punished. This was an interesting statistic. 79.2% of all American Indian and Alaskan natives ages 12 to 17. So your teenagers in 2014 stated that religious beliefs are an important part of their lives and believed that their beliefs shape their decisions. When you look at the majority culture, that percentage is way lower. Having a stronger commitment to traditional spirituality is a protective factor against suicide and some mental and substance abuse disorders. Recognizing that many American Indians and Alaska Natives are Christians, but they incorporate aspects of Native beliefs which may affect their view of the world and their place place in it. So they may reflect on one higher power. However, they respect the sanctity and their connection to everything within the earthly world. And I couldn't find a articulation or a pronunciation online for this word. So if you know the word please share. I'm probably going to butcher it and I apologize, but the Navajo concept of hozo means peace, balance, beauty and harmony. To be in hozo is to be at one with and part of the world around you. Being mindful, being deliberate in your activities. When two people are parting, they may say, may you walk according to hoso. In part, it's a reminder to go about life deliberately. I like this concept. I even created a little infographic just on that particular concept because it's what we talk about with mindfulness and purposeful action. Alaskan Native values show respect to others because each person has a special gift. And I think it's important if you're working with Alaskan Natives to potentially have this available and you can use it in terms of a counseling tool in order to reflect on show respect to others because each person has a special gift. So if someone is having a challenge with another person, you know, maybe we can take a breath and take a step back and go, okay, you're having a disagreement about this, but let's take a minute and think about what's that person's special gift. Embracing the dialectics. Share what you have because giving makes you richer. Know who you are because you're a reflection on your family. Accept what life brings. You cannot control many things that teaches that. Acceptance. Acceptance and commitment Therapy is actually a really good approach to use with Alaskan Natives. Have patience because some things just cannot be rushed. Live carefully. What you do will come back to you. Take care of others, you cannot live without them. Honor your elders because they show you the way in life. Pray for guidance because there are many things that are not known and see connections. All things are related. Now how many of these values could you use when talking with someone in individual or in group in order to help them experience and maybe look at their problem or their challenges from a different point of view or to highlight their strengths? Traditional values which applied to both American Indians and Alaskan Natives. Cooperation, collectivism and harmony. Modesty and humility. And that doesn't necessarily mean being covered from head to toe. It means being respectful that everybody brings things. Not trying to make yourself seem more important, but recognize that everybody has talents and being humble. The fact that you're able to receive gifts from others as well as you've been given the gift of whatever your gifts are. Respect for personal freedom and autonomy. As I said earlier, trust your client to do the next right thing. Try to avoid giving advice because there are many ways to solve a problem and in many ways it's important for people to come to that path and decide on which path to choose on their own. Respect the tradition and elders. Remember that there is a big emphasis on oral tradition. A lot of the stuff. There are some stories and things that have been passed down that you're not even allowed to write down, which is another reason it's important to talk. You're not going to necessarily be able to just email or text with somebody. You may. When working with American Indians and Alaska Natives, you may actually have to get on the phone or have a face to face chat because certain things are inappropriate to write down. Work to meet needs, not to accumulate wealth. Respect generosity. Remember that all of nature is alive and worthy of respect and value. Present focus or mindfulness and patience interventions. Some interventions need to be adapted to be more appropriate for persons who are American Indian or Alaskan Natives. And motivational interviewing is one of those. And I gave you a couple of links. These are available for free online to Native American Motivational Interviewing and the Trainer's Guide to Motivational Interviewing Enhancing Motivation for Change. A Learner's Manual for the American Indian Alaska Native Counselor. Those two are really available. They're really easy to read, to go through. And there are minor changes or alterations that you use in motivational interviewing such as having clients create personal stories for each stage of change in order to adapt motivational interviewing to this population. Trauma Informed approaches are other interventions and that's kind of a big umbrella there. Braveheart wrote historical trauma and unresolved grief interventions so that one has been particularly put out there and modified for American Indian populations. That and Alaskan Natives who have experienced historical trauma. Mindfulness based interventions, you know, really don't need to be modified. Walking meditations is one of the suggestions that they use and you can google it. I found multiple pages on how to do walking meditations but it helps people become more aware and more present in the moment. But it's an active sort of thing so they're not having to sit still and explore how to use mindfulness in traditional practices. Acceptance and commitment therapy uses mindfulness, value based decision making and purposeful behavior. So like I said, it's a really good fit with a lot of people in these cultures. Cognitive behavioral therapy interventions should assume the role of consultant and resource provider and avoid being too directive. And two examples of that I could not find Cognitive Behavioral Therapy with American Indians by McDonald and Gonzales, so there's no link for that. But Cognitive Behavioral Therapy for Native American youth with PTSD symptoms is available and you can click on that link to learn more about how to modify symptoms. CBT to be more culturally responsive Historical trauma, including the loss of culture, lies at the heart of substance use and mental illness. Behavioral health issues are seen as an imbalance in the individual's relationship with the world. Healing and treatment approaches must be inclusive of all aspects of life. Spiritual, emotional, physical, social, behavioral and cognitive providers need to understand how clients perceive their own cultural identity. Again, are they embracing their traditional culture? Are they bicultural? Or are they embracing the majority culture or somewhere in between and how they view the role of traditional practices in treatment. Some may be all about it, some may not want to go anywhere near it. Reconnection to American Indian and Alaskan Native communities and traditional healing practices may help individuals reclaim the strengths inherent in traditional teachings because there's a lot of wisdom there, practices and beliefs, and begin to walk in balance and harmony presenting certain ideas, certain suggestions for interventions might be helpful. Providers in Native and non Native programs need to understand the role of tribal sovereignty, governance systems and treatment referrals, planning and program development. And I said that a bunch. Make sure that you're involving the community in the development of your program. American Indian and Alaskan Native clients and their communities must be given opportunities to offer input on the types of services they need, how they want to receive them. Culturally responsive counselors will explore how culture affects their interactions, their initial diagnostic impressions of clients, and selection of healing interventions. And there are some great activities within TIP61 that help you reflect on your cultural identity and become more Culturally responsive. They did a great job with that. An environment that reflects American Indian and Alaskan Native cultures is more engaging for shows respect to clients who identify with this culture by using Native community vendors, hiring a workforce that reflects local diversity, and offering professional development activities that highlight culturally specific American Indian and Alaskan Native client and community needs. And there is no one right way. Providing direction on how something should be done is not a comfortable or customary practice for American Indians and Alaskan Natives. For them, healing is interconnected with others and comes from within, from ancestry, from stories and from their environment. Like I said, there are multiple paths and they need to understand which path they need to take to be in harmony with their community and with themselves. And finally, the Big B and the American College of Physicians in 2003 created the mnemonic Respect, which is just a reminder. Respect communication styles and how respect is shown in that culture. E stands for explanatory model. Understand how clients perceive and understand their presenting issues. Sociocultural context affects treatment. That's your S. P is for participation expectations for treatment, which may be different than mainstream, which is with this population. They may want to involve family, community, faith healers, whomever. We need to be aware of that. And remember, family may not just be their nuclear family, it can be extended family and even unrelated people. E stands for empathy, gotta have it. C stands for concerns and fears. And we should elicit those at the beginning of treatment to understand. Well, actually before the beginning, when we're talking to the community going, what are your concerns and fears that might prevent you from accessing services? Then at the beginning of treatment, and then at any point of resistance where the person starts going, yeah, no, this is not comfortable. What's going on. Trust is based on who you are and not what you accomplished. In these particular cultures. It is important to remember that you can have degrees all over your wall, but it's about who you are as a person. Are you genuine, are you connected, are you responsive, etc. So that is your mnemonic for culturally responsive counseling with American Indians and Alaskan Natives. Other resources, you can click on these links. All of these are from samhsa, but it gives you some more ideas about what you might need to know. How do you deal with confidentiality when healers, family and community are involved? Well, the first thing, in order to get them involved, we have to have a release of information from the client. When you're working with traditional healers, then you have a release of information with that person and their ethics are going to govern what they can and cannot release. Just like when you're working with anybody else. And just like in, you know, mainstream counseling, if you will, when you're working with a family, the quote, identified patient can set limits on how much or how little the family is involved. But then once you get the family involved, then you all have a certain amount of or the whole family has a certain amount of onus to respect confidentiality. And if you're getting the community involved, that is something that is a choice of the individual. And they're obviously choosing to waive their confidentiality at that point. But you're going to talk to them ahead of time and obviously you're not going to be reading their assessment and progress notes to their whole community. You're going to talk to them ahead of time about what they feel comfortable sharing and generally let them take the lead in sharing, because we are consultants in this role. Let them take the lead in sharing with their community what they need to in the circles or wherever in order to find or regain their sense of balance and connection. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allceus.com Sponsor thank you.