Chapter Objectives

1. Learn the demographics and characteristics of American Indians and Alaska Natives.

2. Identify counseling implications of the information provided for American Indians and Alaska Natives.

3. Provide examples of strengths that are associated with American Indians and Alaska Natives.

4. Know the special challenges faced by American Indians and Alaska Natives.

5. Understand how the implications for clinical practice can guide assessment and therapy with American Indians and Alaska Natives.

Of the 175 Indian languages once spoken in the United States, only about 20 are still passed on to younger generations. James Jackson, Jr., remembers his experience in a boarding school when a teacher grabbed him when he was speaking his native language and threatened to wash out his mouth with soap: “That’s where we lost it [our language].” (Brooke, 1998)

In 2010, the University of North Dakota agreed to retire the fighting Sioux name and logo to comply with a ban from the NCAA (National Collegiate Athletic Association). Do the Native-themed mascots or logos impact the psychological well-being of American Indians? The American Psychological Association (2005) believes such symbols and imagery undermine respectful and accurate images of the American Indians’ culture.

In 2014, the city of Eureka, California, drafted an apology to the Wiyot tribe for the 1860 massacre on Indian Island, during which 200 sleeping Wiyot, including women and children, were slaughtered. The City Council removed the apology part of the letter for fear of opening itself up to liability and substituted language acknowledging that the Wiyot people had been massacred but not stating who was responsible. (Lee, 2015)

American Indians/Alaska Natives form a highly heterogeneous group composed of 566 distinct tribes, some consisting of only four or five members (Bureau of Indian Affairs, 2014). The American Indian and Alaska Native population was 3.8 million, representing 1.2% of the total U.S. population (U.S. Census Bureau, 2014). An additional 1.81 million Americans report having Indian roots. About 34% of American Indians live on reservations, whereas 57% reside in metropolitan areas (Bureau of Indian Affairs, 2011). Fewer American Indians are high school graduates than the general U.S. population (71% versus 80%). American Indians have the highest national poverty rate, 27%, with income only 69% of the mean income of all households (Macartney, Bishaw, & Fontenot, 2013). American Indians differ in their degree of acculturation. Although most do not live on reservations or with their tribes, many are returning because of casino jobs or a more nurturing environment. One man who returned described his need for a more “friendly place, friendly face, and friendly greetings” (Shukovsky, 2001, p. A1).

What constitutes an Indian is often an area of controversy. The U.S. Census depends on self-report of racial identity. Congress has formulated a legal definition: An individual must have an Indian blood quantum of at least 25% to be considered an Indian. This definition has caused problems both within and outside the Indian community. Some tribes have developed their own criteria and specify either tribal enrollment or blood quantum levels. Tribal definitions typically allow inclusion of the 60% of American Indians who have mixed heritage, including Black, White, and Latino/a backgrounds (Trimble, Fleming, Beauvais, & Jumper-Thurman, 1996).

Because American Indian/Native American and Alaska Natives (AI/AN) comprise such a small percentage of the U.S. population, they are relatively “invisible,” which makes information about them susceptible to stereotypes. This is one of the reasons many oppose the use of Indian-themed mascots and logos. American Indians want the ability to define themselves and are aware of the harmful effects of stereotyped portrayals (Jacobs, 2014). American Indian high school and college students who viewed these types of images reported higher levels of depression, lower self-esteem, and decreased feelings of community worth (Fryberg, Markus, Oyserman, & Stone, 2008). In examining online responses to this controversy, Steinfeldt et al. (2010) found hostile attitudes from non-Indian respondents who did not appear to understand the issues involved: “If the nickname is taken away, we should take away Indian educational programming and funding” and “We are being victimized by reverse racism and PC society.”

Health statistics reveal significant concerns. The death rate by any cause is nearly 50% higher for AI/AN persons than for White individuals (Espey et al., 2014). The alcoholism mortality rate is over twice as high for Indians as for the U.S. population as a whole (Centers for Disease Control and Prevention, 2008). AI/AN individuals have death rates for unintentional injuries due to motor vehicle traffic crashes, poisoning, and falls that are 1.4 to 3 times higher than among Whites (Murphy et al., 2014). Injuries and violence account for 75% of all deaths for American Indian/Native American and Alaska Native Americans between the ages of 1 and 19. These populations also suffer disproportionately from depression, anxiety, and substance abuse (Office of Minority Health, 2012). Among Native American women at a private care facility in New Mexico, 21% reported mood disorders, 47% had an anxiety disorder, and 14% had alcohol dependence or abuse issues. These rates are 2 to 2.5 times higher than found in the general population (Duran et al., 2004).

Characteristics and Strengths

In the following sections we discuss the characteristics, values, and strengths of American Indian/Native Alaska populations and consider their implications in treatment. Remember that these are generalizations and that their applicability needs to be assessed for particular clients and their families.

Tribal Social Structure

For the many American Indians, living both on and off reservations, the tribe is of fundamental importance. The tribe and the reservation, an interdependent system, provide Native Americans with a sense of belonging and security. Tribal connections are significant because individuals see themselves as an extension of their tribe. Status is achieved, and rewards gained, by adherence to tribal structure. Indians judge themselves in terms of whether their behaviors are of benefit to the tribe. Personal accomplishments are honored and supported if they serve to benefit the tribe.


Interventions and decision-making with American Indian/Native American and Alaska Native individuals should take into account the importance placed on tribal relationships. In a study of 401 American Indian/Native American youth (half tribal-based and half urban-based), urban-based youth were more likely to identify personal, familial, and environmental strengths than were tribal-based youth, whereas the latter identified more tribal strengths (Stiffman et al., 2007). The tribe is very important for many Indians, even those who do not reside on the reservation. Many use the word here to describe the reservation and the word there to describe everything that is outside. The reservation is a place to conduct ceremonies and social events and to maintain cultural identity. Indians who leave the reservation to seek greater opportunities sometimes report losing their sense of personal identity (Lone-Knapp, 2000).

Family Structure

It is difficult to describe “the Indian family.” It varies from the matriarchal structures seen in the Navajo, where women govern the family, to patriarchal structures, in which men are the primary authority figures. Some generalizations can be made, however. A high fertility rate, out-of-wedlock births, and strong roles for women are commonly seen. For most tribes, the extended family is the basic unit. Children are often partially raised by relatives such as aunts, uncles, and grandparents, who live in separate households (Garrett, 2006).


The concept of the extended family is often misunderstood by those in the majority culture who operate under the concept of the nuclear family. Misinterpretations are possible if a counselor believes that parents should raise and be responsible for their own children. The extended family often includes distant relatives and even friends. It is not unusual for children to stay in multiple households. In work with children, counselors should determine the roles of various family members, so that interventions can include appropriate individuals. The emphasis on collectivism is strong. If the goals or techniques of therapy lead to discord within the family or tribe, they will not be effective. Interventions may need to include the input of family, relatives, friends, elders, or tribal leaders.

Cultural and Spiritual Values

Because of the great diversity and variation among American Indians/Native Americans, it is difficult to describe a set of values that encompasses all groups. However, certain generalizations can be made regarding common values (Garrett & Portman, 2011; Jumper-Reeves, Dustman, Harthun, Kulis, & Brown, 2014).

1. Sharing. Honor and respect are gained by sharing and giving, in contrast with the dominant U.S. culture, where status is gained by the accumulation of material goods.

Implications : Once enough money is earned, youth and adults may stop working and spend time and energy in ceremonial activities. The accumulation of wealth is not a high priority but is a means to enjoy the present. Interventions targeting alcohol or drug use should take into consideration the emphasis on sharing.

2. Cooperation. Having a harmonious relationship is important and the tribe and the family take precedence over the individual. The children are often sensitive to the opinions and attitudes of their peers and may actively avoid disagreements or contradictions. Most do not like to be singled out and made to perform in school unless the whole group benefits.

Implications : Instead of going to work or school, children or adults may prioritize assisting a family member needing help. Children may be seen as unmotivated in school because of their reluctance to compete with peers.

3. Noninterference. It is important not to interfere with others and observe rather than react impulsively. Rights of others are respected. This belief in noninterference extends to parenting style.

Implications : Culture significantly shapes parent–child relationships. American Indians/Native Americans are more indulgent and less punitive than parents from other ethnic groups (BigFoot & Funderburk, 2010). EuroAmerican parenting styles may conflict with American Indian values. One culturally sensitive parent education program developed for this population included (a) use of the oral tradition of storytelling to teach lessons to children; (b) understanding the spiritual nature of child rearing and the spiritual value of children; and (c) use of the extended family in child rearing. The eight-session program included social time for parents and children before each session, including storytelling and a potluck meal. The program applied traditional teaching methods, such as nurturing, use of nature to teach lessons, and use of harmony as a guiding principle for family life (Gorman & Balter, 1997).

4. Time orientation. There is a greater focus on the present than on the future. Ideas of punctuality or planning for the future may be unimportant. Life is to be lived in the here and now.

Implications : Tasks may be approached from a logical perspective rather than according to deadlines. In contrast, the U.S. majority culture values delay of gratification and planning for future goals. In working with these issues, the counselor should acknowledge such value differences and help the individual or family develop strategies to negotiate value conflicts.

5. Spirituality. The spirit, mind, and body are all interconnected. Illness involves disharmony between these elements. Positive emotions can be curative; healing can take place through events such as talking to an old friend on the phone or watching children play (Garrett & Wilbur, 1999).

Implications : Traditional curative approaches attempt to restore spirit–mind–body harmony. The sweat lodge and vision quest are often used to reestablish connections between the mind, body, and spirit. To treat a problem successfully, all of these elements may need to be considered and addressed. Counselors can help clients identify factors involved in disharmony; determine curative events, behaviors, and feelings; and use client-generated solutions to create balance.

6. Nonverbal communication. Learning occurs by listening rather than talking. Families tend to ask few direct questions. Direct eye contact with an elder may be seen as a sign of disrespect.

Implications : Differences in nonverbal communication can lead to misunderstandings. For example, lack of eye contact or direct communication may be viewed as a sign of disrespect. It is important to determine whether specific behaviors are due to cultural values or are actual problems.

Cultural Strengths

American Indian/Native American and Alaska Native populations had to endure extermination and assimilation efforts and were able to do so because of cultural values and strengths such as spirituality; respect for traditional values and ceremonies; extended family networks; allegiance to the family, community, and tribe; wisdom of the elders; respect for the environment and the land; connection to the past, adaptability, and the promotion of such themes as belonging, mastery, independence, and generosity (APA, 2014; Gilgun, 2002). The values of listening and observing rather than reacting can enhance communication and decrease conflict. Spiritual and traditional practices also act as a protective factor (Garroutte et al., 2003). The respect shown for the environment and the interconnection between humans and the environment is something that can be emulated by all cultures. Additionally, the focus on the present is increasingly recognized as an asset, particularly among those who incorporate mindfulness activities into clinical practice (Chiesa & Serretti, 2011).

Specific Challenges

In the following sections we describe the challenges often faced by American Indian/Native American populations and consider their implications in treatment.

Historical and Sociopolitical Background

In North America, wars and diseases that resulted from contact with Europeans decimated the American Indian/Native American population; by the end of the 18th century, only about 10% of the original population remained. Additionally, the tribes suffered massive loss of their land. Their experience in America is not comparable to that of any other ethnic group. In contrast to immigrants, who arrived with few resources and struggled to gain equality, American Indians/Native Americans originally had resources. However, their land and status were severely eroded by imperial, colonial, and then federal and state policies (Johnson et al., 1995). For years, extermination and seizure of lands seemed to be the primary governmental policy toward Indians.

In the 1830s, more than 125,000 people from different tribes were forced from their homes in many different states to a reservation in Oklahoma. The move was traumatic for their families and, in many cases, disrupted their cultural traditions. Assaults against their culture also occurred in the form of attempts to “civilize” them. Children were removed from their families and placed in English-speaking boarding schools. They were not allowed to speak their own language and were forced to spend 8 continuous years away from their families and tribes. Children were also removed from their homes and placed with non-Indian families until the Indian Child Welfare Act of 1978 prohibited these practices (Choney, Berryhill-Paapke, & Robbins, 1995; Johnson et al., 1995). However, during the 1998 congressional hearings regarding possible amendments to the Indian Child Welfare Act, statistics were cited indicating that over 90% of American Indian children were still being placed by state courts and child welfare workers into non-Indian homes (Congressional Record, 1997). Although amendments to the original act dramatically reduced this type of placement, the National Indian Child Welfare Association (2014) and other advocacy organizations recently asked the Department of Justice to investigate Indian Child Welfare Act violations.

These disruptive events had a tremendous negative impact on family and tribal cohesion and prevented the transmission of cultural values from parents to children. Some professionals believe that the experiences of colonization, coercive assimilation experiences in boarding schools, and the widespread loss of indigenous languages and customs may result in “historical trauma” in which the distress and dysfunction experienced by an individual can be passed down intergenerationally (Gone, 2014). Individuals may have unresolved grief—“soul wounds”—that lead to behavioral dysfunction and substance abuse. The following case study illustrates some of the disruptions caused by a boarding school experience.

Case Study


Mary was born on the reservation. She was sent away to school when she was 12 and did not return to the reservation until she was 20. By the time she returned, her mother had died from pneumonia. She didn’t remember her father, the medicine man of the tribe, very well. Shortly after she returned, she became pregnant by a non-Indian man she met at a bar. Mary’s father . . . looked forward to teaching and leaving to his grandson, John, the ways of the medicine man . . . . John felt his grandfather was out of step with the 20th century . . . . Mary . . . could not validate the grandfather’s way of life . . . [because] she remembered having difficulty fitting in when she returned to the reservation . . . . In response to the growing distance between her father and her son, she became more and more depressed and began to drink heavily. (Sage, 1997, p. 48)

In the past, the tribe, through the extended family, was responsible for the education and training of children. The sense of tribal identity developed through this tradition was significantly eroded by governmental policies. In addition, even recent history is full of broken treaties, the seizure or misuse of Indian land, and battles led by local or federal officials to remove or severely limit fishing and hunting rights. Thus American Indians/Native Americans are often suspicious of the motives of the majority culture; many expect that they will not be treated fairly by non-Indians (Cruz & Spence, 2005).


When working with children and families, it is important to consider the historical sociopolitical relationship between American Indians/Native Americans and the local, state, and federal government. The counselor should understand not only the national history of oppression but also local issues and specific tribal history.

The historic disruption of families resulting in the Indian Child Welfare Act has important implications for how American Indians/Native Americans might view child protective services or respond to runaway youth. Currently, decisions regarding the placement of their children are held in tribal courts. Testimony from expert witnesses familiar with the specific tribal or cultural group must be obtained before children can be removed from their homes. Additionally, if children are removed from their parents, residence with extended family members, other tribal members, or other American Indian/Native American families is given primary consideration.

Educational Concerns

There is a high rate of school failure among American Indian/Native American and Alaska Native populations (Whitesell, Mitchell, Spicer, & the Voices of Indian Teen Project Team, 2009) and they have the lowest postsecondary graduation rate of any minority group (National Center for Education Statistics, 2013). In fact, the educational achievement gap of American Indian/Native American and Alaska Native youth with White youth has widened in recent years (Education Trust, 2013). The children appear to do well during the first few years of school. However, by the fourth grade, a pattern of academic decline and truancy develops; a significant drop in achievement motivation often occurs in middle school. Although some have argued that traditional cultural values and beliefs are incompatible with those of the educational system, there is increasing support for the view that perceived barriers to mobility are the culprit for reduced academic performance. In other words, academic success is not perceived as leading to rewards or success. Some contend that once children realize their “Indianness,” achievement motivation drops (Wood & Clay, 1996). In addition, many youth see that jobs are available in casinos or on the reservation, so they do not see the value in pursuing a “White man’s education.” Many never finish high school. Only 13% have a bachelor’s degree, versus 28% of the U.S. population (Ogunwole, Drewery, & Rios-Vargas, 2012). Such educational gaps are believed to perpetuate the cycle of poverty and reduced opportunities and may contribute to the high suicide rate among American Indian adolescents (Keane, Dick, Bechtold, & Manson, 1996).


The blame for school failure has generally been placed on the individual rather than on the school environment. However, many youths who leave school report feeling “pushed out” and express mistrust of teachers who represent the same White community that has historically exerted control over the economic, social, and religious lives of Indians (Deyhle & Swisher, 1999). At a systems level, positive changes could occur if public schools and institutions of higher education (a) recognized the sociocultural history of American Indians/Native Americans and acknowledged their perceptions of schools as a potentially hostile environment and (b) increased efforts to accommodate some of the social and cultural differences of the students, including adapting curricula to reflect these students’ cultural background (Reyhner, 2002). The perceived lack of reward for academic achievement also needs to be addressed. Schools must help students bridge the two worlds of American Indian/Native American and White cultures. Some tribes have given up on the public school system and have developed their own learning centers and community colleges.

The AlterNative Education Program was created to interest American Indians/Native Americans in postsecondary education. It recruits indigenous students and alumni at Columbia University to travel to reservations in New Mexico and teach high school–aged youth about their identity and past. The program covers areas such as oppression, stereotypes, and colonialism; focuses on identity building; and encourages higher education. Responses from the participants have been quite positive and have resulted in increased interest in college enrollment (Aronowitz, 2014).

Acculturation Conflicts

When I attended the university, that’s the first time I saw a powwow. . . .It’s only now [that] I start learning my culture.

I don’t know the meaning of the symbols of our culture. Instead, I know the symbols of the Catholic faith. (Gone, 2009, p. 757)

Not only do Indian children and adolescents face the same developmental issues as other youth, but they also may experience conflict over exposure to two very different cultures, a factor that may result in failure to develop a positive self-image or strong ethnic identity (Garrett & Portman, 2011). Many youth are caught between the expectations of their parents to maintain traditional values and the necessity to adapt to the majority culture (Rieckmann, Wadsworth, & Deyhle, 2004). In one study of adolescents, the most serious problems identified involved ethnic identity, family relationships, grades, and concerns about the future. One-third of the girls surveyed reported feeling they did not want to live (Bee-Gates, Howard-Pitney, LaFromboise, & Rowe, 1996).

Many Indians are acculturated and hold the values of the larger society. The degree to which a client identifies with the native culture or is acculturated to U.S. culture should always be considered. Garrett and Pichette (2000) have formulated five levels of cultural orientation:

1. Traditional. The individual may speak little English and practice traditional tribal customs and methods of worship.

2. Marginal. The individual may be bilingual but has lost touch with his or her cultural heritage, yet is not fully accepted in mainstream society.

3. Bicultural. The person is conversant with both sets of values and can communicate in a variety of contexts.

4. Assimilated. The individual embraces only the mainstream culture’s values, behaviors, and expectations.

5. Pantraditional. The individual has been exposed to and adopted mainstream values but is making a conscious effort to return to the “old ways.”


Counselors need to discuss the client’s tribal affiliation (if any), languages spoken, self-identity, and residential background, and find out whether there is a current relationship to a tribe or tribal culture (Garrett & Pichette, 2000). The types of problems and the therapeutic process and goals appropriate for someone living on a rural reservation may be very different from those appropriate for an urbanized Indian who retains few traditional beliefs. Individuals with a traditional orientation may be unfamiliar with expectations of the dominant culture and may want to develop the skills and resources to deal with mainstream society. In contrast, assimilated or marginal American Indians may want to examine self-identity conflicts and may face issues such as (a) lack of pride in or denial of their heritage, (b) pressure to adopt majority cultural values, (c) guilt over not knowing or participating in the cultural customs or events, (d) negative views regarding their group, and (e) a lack of an extended support or belief system. It may be healthiest to have a bicultural orientation which allows the individual to live in both worlds. This perspective appears to confer strength and resiliency in American Indians (Flynn, Olson & Yellig, 2014).

The client’s level of acculturation should also be a factor that guides the therapist’s selection of therapeutic interventions. For example, acculturated and bicultural American Indians/Native Americans have found success with all components of cognitive behavior therapy (CBT), whereas those who are traditionally oriented are responsive to the short-term focus, activity schedule, and homework assignments in CBT but have difficulty with the underlying theoretical assumptions regarding the association between thoughts and emotional symptoms (Jackson, Schmutzer, Wenzel, & Tyler, 2006). In these cases, modified explanations for CBT may be useful.

Alcohol and Substance Abuse

D1 talked about lack of things to do on the reservation and how it related to substance abuse: That’s all there is to do. There’s really not much going on, especially on the reservation, but to drink and get high. I mean from what I’ve seen before, that’s all you really have to look forward to is getting high or getting drunk (Myhra & Wieling, 2014, p. 306).

Substance abuse is one of the greatest problems faced by American Indian/Native American and Alaska Native populations. Many youth begin substance use at an early age, use multiple substances, and maintain high levels of use during adolescence (Boyd-Ball, Véronneau, Dishion, & Kavanagh, 2014). Although rates of alcohol use vary across tribes and regions, American Indians/Native American and Alaska Natives have the highest weekly alcohol consumption of any ethnic group (Chartier & Caetano, 2010). Thus alcoholism is a significant concern for many tribes (Spillane, Cyders, & Maurelli, 2012). However, it must be remembered that there is variability in alcohol-use patterns between specific subgroups; for example, Southwest Indians, especially females, have low rates of alcohol consumption (Chartier & Caetano, 2010).

A variety of explanations have been put forth for the high levels of alcohol abuse. Although drinking alcoholic beverages may initially have been incorporated into cultural practices as an activity of sharing, giving, and togetherness (Swinomish Tribal Mental Health Project, 1991), heavy alcohol use is associated with other factors, such as feelings of powerlessness (Taylor, 2000). Substance abuse is also related to low self-esteem, cultural identity conflicts, lack of positive role models, childhood maltreatment, social pressure to use substances, hopelessness about life, and a breakdown in the family (Whitesell, Beals, Crow, Mitchell, & Novins, 2012)).


Successful drug treatment programs have incorporated appropriate cultural elements. Because peers often support substance use, prevention and interventions should involve not only the individual but also the community and family, including siblings, cousins, and friends (Boyd-Ball, Véronneau, Dishion, & Kavanagh, 2014). One tribal community reduced their alcoholism rate from 95% to 5% in 10 years by revitalizing traditional culture and taking a strong community stance against alcohol abuse (Thomason, 2000). Many tribes have developed similar programs to deal with alcohol- and drug-abuse issues. Programs have the greatest chance of breaking the cycle of substance abuse when they incorporate cultural strengths, evidence-based strategies, and traditional tribal practices such as talking circles and ceremonies (Jumper-Reeves et al., 2014).

Domestic Violence

The rate of domestic violence, along with physical and sexual assault, is quite high in many native communities. Statistics indicate that American Indian/Native American and Alaska Native women experience domestic violence and physical assault at much higher rates than women of other ethnicities (Peters, Straits, & Gauthier, 2015). Native women often experience sexual and physical abuse early in life; abuse is especially high among lesbian and bisexual women (D’Oro, 2010). The high incidence of domestic violence may result from changes in traditional roles for men and women, as well as substance abuse and stressors associated with social and economic marginalization. There is an intergenerational pattern of violence in many families in which individuals who witnessed family or domestic violence become aggressive with their own partners (Myhra & Wieling, 2014). Thus the cycle of violence is perpetuated.


During counseling, it may be difficult to determine whether domestic violence is occurring within a family or couple. Native American women who are abused may remain silent because of cultural barriers, a high level of distrust of White-dominated agencies, fear of familial alienation, and the historical failure of state and tribal agencies to protect women from domestic crimes (Wahab & Olson, 2004). Jurisdictional struggles between state and tribal authorities can also result in a lack of help for women. Many tribes acknowledge the problem of family violence and have developed community-based domestic violence interventions using strategies from the Indian cultural perspective (Hamby, 2000). When working with a domestic-violence issue with an Native American woman, tribal issues, tribal programs, and family support options should be identified.


At the Montana Indian Reservation, sixteen-year-old Franci Jackson considered hanging herself with a rope when she felt she couldn’t take any more bullying at school. But then she changed her mind. “I thought of my mom and dad and how much they love me. And if I leave, what would they do without me? But most kids don’t think,” she said in tears. Six American Indian students living in her area had killed themselves in the previous year with another 20 attempting suicide. (Associated Press, 2011)

Suicide rates have reached epidemic proportions among American Indian/Native American and Alaskan Natives. For individuals between the ages of 15 and 34 years, the suicide rate is about 250 percent higher than the general population and is the second leading cause of death among those aged 15 to 34 years (Centers for Disease Control and Prevention, 2013). Adolescence through early adulthood is the time of greatest risk for suicide, especially among males (Middlebrook, LeMaster, Beals, Novins, & Manson, 2001). American Indian/Native American and Alaska Native youth have twice the rate of attempted and completed suicide as other youth (D’Oro, 2011). Among a sample of 122 middle-school children living on a North Plains reservation, 20 percent had made a nonfatal suicide attempt and of this group, nearly half had attempted suicide two or more times (LaFromboise, Medoff, Harris, & Lee, 2007). Death rates from suicide are highest among AI/NA/AN populations in Alaska and in the northern plain states (Herne, Bartholomew, & Weahkee, 2014). The high incidence of suicide is associated with alcohol abuse, poverty, boredom, family breakdown, and disconnection from their culture and community (Gray & McCullagh, 2014).


There are many societal and economic issues facing American Indians/Native Americans and Alaska Natives. For those who live on a reservation or identify with a tribe, community activities sometimes focus on reducing suicidal ideation and promoting resilience in youth. Effective programs need to be culturally consistent. For example, many Indians believe that mental health issues are due to unbalanced spiritual relationships (Limb & Hodge, 2010). In traditional belief systems, there is not only a seen world but also an unseen world. Events that disrupt the unseen world disturb the harmony in the seen world. Therefore, if intervention focuses only on the seen world, change will likely not occur (Cruz & Spence, 2005).

A promising culturally tailored suicide intervention program was implemented by LaFromboise and Howard-Pitney (1995) at the request of the Zuni Tribal High School. Scores on a suicide probability measure indicated that 81% of the students were in the moderate-to-severe risk range. Of the participants, 18% reported having attempted suicide, and 40% reported knowing of a relative or friend who had committed suicide. The program included role-playing, building self-esteem, identifying emotions and stressors, recognizing and eliminating negative thoughts or emotions, receiving information on suicide and intervention strategies, and setting personal and community goals. The program was effective in reducing feelings of hopelessness and suicidal probability ratings. Intervention programs may need to be developed based on the needs of individual tribes. For example, although among the Pueblo suicidal ideation was associated with the suicidal behavior of friends, for adolescents from Northern Plain tribesthe most significant factors were low self-esteem and depression (LaFromboise, 2006).

Implications for Clinical Practice

1. Explore the client’s ethnic identity, tribal affiliation, and adherence to cultural values. Also, discuss family members’ association with a tribe or reservation and the importance of rituals or ceremonies in healing. In addition, determine the appropriateness of a mind-body-spirit emphasis. Keep in mind that many American Indians adhere completely to mainstream values, whereas others, especially those living on or near reservations, are more likely to hold traditional values (Peters et al., 2015).

2. Understand the extensive history of oppression and social injustice experienced by American Indians and learn about local issues associated with the client’s tribe or reservation.

3. Learn about the client using a client-centered listening style, and gradually determine when it is appropriate to use more structure and questions. Try not to hurry the individual. Allow sufficient time for clients to finish statements and thoughts. Be aware that some clients may prefer brief interventions (Flynn et al., 2014).

4. Assess the problem from the perspective of the individual, family, extended family, and, if appropriate, the tribal community; attempt to determine the role of cultural and experiential factors and if they have seen a traditional healer.

5. If necessary, address basic needs such as problems involving food, shelter, childcare, and employment. Identify possible resources, such as Indian Health Services or tribal programs.

6. Be alert for problems such as domestic violence, substance abuse, depression, and suicidality.

7. Identify possible environmental contributors to problems, such as racism, discrimination, poverty, and acculturation conflicts; consider how knowledge of these factors can help reduce self-blame.

8. Help children and adolescents determine whether cultural values or an unreceptive environment contribute to their problem. Strategize different ways of dealing with these conflicts. For some, strengthening their sense of cultural identity can be helpful.

9. Help determine concrete goals that incorporate cultural, family, extended family, and community perspectives.

10. Determine whether child-rearing practices are consistent with traditional methods and how they may conflict with mainstream methods.

11. In family interventions, identify extended family members, determine their roles, and request their assistance when appropriate.

12. Generate possible solutions with the client and consider the possible consequences of change from individual, family, and community perspectives. When appropriate, include strategies that may involve cultural elements and that focus on holistic factors (mind, body, spirit).


American Indian/Native American and Alaska Natives comprise such a small percentage of the U.S. population that they are relatively “invisible.” Life-expectancy and mental/physical health problems, however, are among the worst for this population. Their experience in America is not comparable to that of any other ethnic group. In contrast to immigrants, who arrived with few resources and struggled to gain equality, they originally had resources, which were severely eroded or destroyed by imperial, colonial, and federal and state policies. Alcohol and substance abuse, domestic violence, and suicide are among the most problematic disorders facing this population. In work with AI/NA/AN, counselors need to understand how the values of sharingcooperationnoninterference, time orientation, spirituality, and nonverbal communication are relevant to mental health practice. Twelve clinical implications for counselor practice are identified.

Glossary Terms



Extended family


Nonverbal communication




Sweat lodge


Vision quest

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