Native American Adolescents: A Systematic Review of Indigenous Pathways to Resilience Sheena Brown PhD MPH Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson AZ

Background “The experts talk about our community in terms of statistics and numbers. They don’t realize that these statistics are our friends, cousins, and brothers. They [the experts] don’t know that they might have had a brilliant future or who they were before bad things happened to them. They just have them as a statistic.” Jaron Kie (17), Laguna youth group Albuquerque, New Mexico “This is my concern, that mental health … is bad, you have horrible statistics but no information about why it is so horrible. So, if you treat the symptom of alcoholism and not have it in the context of historical trauma, you are to miss what really the whole family is suffering from. What the whole generation is suffering from. So, this is my big concern that historical trauma doesn’t really get assessed as a diagnosis, it doesn’t get treated.” Native American Community Leader UCDavis CRHD, 2009

American Indians and Alaska Natives (AIAN) are frequently among the most highly vulnerable populations including those who are homeless, incarcerated, and victims of trauma AIAN youth  75% of deaths AIAN youth (12-20yrs): intentional injury, homicide, suicide*  79% of youth in the Federal prison system are AIAN**  50% national high school graduation rate Literature Review:  Mental health issues of AIAN adolescents; programs, program needs, inequalities, risk and protective factors  Explore the concept of resilience as a protective factor *SAMHSA **Bureau of Justice Statistics, 2004 Background

Methods Databases searched: Pubmed, EBSCO, Web of Science To be included the article had to: 1.Be written in English 2.Be peer-reviewed and published before May Identify AIAN adolescents 4.Specify mental health focus 5.Identify social and environmental factors Search terms: Native American, American Indian, Alaska Native, Adolescent mental health, Adolescent and family mental health

Results – Literature Review Peer reviewed articles (n=28) Peer reviewed articles (n=28) Number of journal articles identified in database search (n=772) Number of journal articles identified in database search (n=772) Titles and abstracts with epidemiological, clinical and non- definitive age focus excluded (n=710) Titles and abstracts with epidemiological, clinical and non- definitive age focus excluded (n=710) Number of articles reviewed by primary categories (n=62) Mental Health Services (n=10) n=6 Mental Health Services (n=10) n=6 Mental Health Inequities (n=10) n=3 Mental Health Inequities (n=10) n=3 Mental Health Needs (n=8) n=6 Mental Health Needs (n=8) n=6 Risk Factors (n=10) n=7 Risk Factors (n=10) n=7 Articles excluded as Other ( n=18 ) Articles excluded as Other ( n=18 ) Articles excluded, policy and/or off-topic focus ( n=16 ) Articles excluded, policy and/or off-topic focus ( n=16 ) Protective Factors (n=6) n=6 Protective Factors (n=6) n=6 N=44

Mental Health Services Services predominantly community based and federally funded Program protocols originated from non-native communities Medicalization of mental health issues Pharmaceutical influence on mental health diagnoses Insufficient staff numbers Political, economic, institutional forces interpreted as MH issues Obstacles Self-reliance Quality of care Communication / trust

Mental Health Inequities AIAN adolescents suffer from disproportionately high rates of certain mental disorders and suicide Substance abuse Disruptive behavior disorder Suicide Incarceration Effective mental health services remain in short supply Lack of Native clinicians Distrust of non-Native clinicians Funding

Mental Health Needs “The year 1992 was declared the "Year of the American Indian.” As we begin the new year, I am certain that all Americans want to continue to observe the respect that Native Americans deserve, by doing our best to raise Indian health status to the highest level possible by the year 2000” Inouye 1993 Negligible mental health services available to AIAN youth 1 provider: 23,000 youth (Inouye 1993) Providers not always equipped to respond Lack of facilities for youth

Risk Factors Intergenerational trauma Alienation from family / lack of family cohesion Lack of meaning and purpose, hopelessness Exposure to violence Grief and loss Poverty Unemployment Abuse Stigma Protective Factors Community & family support Family connection Supportive peer networks Meaning & purpose, hope Culture & Ceremony Traditional healing Spirituality Ethnic identity optimism, self-esteem

Recommendations 1.Mental Health Services The role of cultural, religious, and often social values and beliefs are poorly understood and accepted, by the general population Evaluation of the role of traditional healers working with adolescents Re-evaluate requirements for certification of lay-MH counselors The traditional holistic approach is different to non-Native MHS

Recommendations 2.Mental Health Inequities Tailor or augment existing mental health treatments and services or… Reimagine MH approaches with local communities Family involvement – key protective factor Funding: evidence vs innovation

Recommendations 3.Mental health needs Family is a key protective factor Youth involvement, Family involvement, Community involvement Mental health services incorporated into education system Program focus on values of individual communities

Resilience The ability to rise above adversity All communities have strengths – deficit based programs negatively define, label and blame individuals Community resilience; moving beyond labels Risk and protective factors are context & environment dependent

Who Decides What Is And What Is Not Mental Illness? “Mental illnesses without aberrant symptomatology may not be viewed as illness at all” (Keltner 1993) Prior to European contact, there was no concept of mental illness per se.  Among various AIAN people, mental illness is viewed as: (a) a form of supernatural possession (b) an imbalance and disharmony with the inner and outer natural forces in the world (c) the expression of a special gift Source: Grandbois 2005

Worldview Differences that Impact Mental Health Care American Indian/Alaska Native Majority culture Relational, circular Linear, point A to B Mind, body, spirit/One Psyche is the focus Mystical/acceptance Scientific/verification Ceremonials/rituals Psychotherapy Tribal connectedness Individualism Spirituality & balance Organized religions Cooperation/sharing Competition/winning Patience/respectful Assertive/forceful Present oriented Future oriented Herbs, plants, nature Psychopharmacology Source: Grandbois, 2005 (Table 2). Who decides what is, and is not mental illness?

Conclusions Native initiated programs Culturally appropriate evaluations Increase tribal access to core Federal funding sources Economic needs of youth must be addressed Youth need to have important roles in the community Need meaning & a sense of autonomy in their lives Education system – does it currently serve the needs of youth? Program focus on family cohesion and community strengths Reduce emphasis on defining the problem Much information is not in the peer-reviewed literature

Contact Information: Dr. Sheena Brown This work was supported by the Center for American Indian Resilience (CAIR) a NIH-NIMHD P20 Exploratory Center of Excellence (1P20MD006872) awarded to Northern Arizona University with subcontracts to University of Arizona and Diné College Photograph by Sebastião Salgado

References Grandbois, D. M Stigma of mental illness among American Indian and Alaska Native Nations: Historical and Contemporary perspectives. Issues in Mental Health Nursing, 26:1001–1024. Inouye DK Our future is in jeopardy: The mental health of Native American adolescents. J. Health Care Poor &Underserved. 4: 6-8 Keltner BR Native American Children and Adolescents: Cultural Distinctiveness and Mental Health Needs. JCPN 6(4): U.S. Congress, Office of Technology Assessment. Indian adolescent mental health. OTA-H-446. Washington, DC: U.S. Government Printing Office, 1990.