The Suicidal Indian: Exploring the State of Mental Health and Healthcare in the Native American community Introduction In a 1975 article in the Journal of Psychiatry, James Shore tells us the story behind the conception of the stereotype of the "suicidal Indian." In 1968, Senator Robert Kennedy visited the inter mountain Indian reservation on the same day the community had experienced a suicide related death. Becoming the topic of conversation for the day, American Indian suicide came to the attention of the U. S. government resulting in the discovery that the rate of suicide within the American Indian population was approximately 100 per 100, 000, almost ten times the national average. (Tomren 1999).

American Indians and Alaska Indians (AI/AN) exhibit suicide-related behaviors at rates much higher than the general population (Manson 2003). Suicide-related behavior is described as suicide, suicide attempts, and suicide ideation. American Indians and Alaska Natives have the highest rates of suicide of all ethnic groups in the United States (15-24 yrs. ). Suicide is the second leading cause of death for American Indian youth. As recently as 2001, there were 4 million American Indian and Alaskan American Indian people in the Unites States representing only 1.

5% of the total population. They are a fairly young population with the mean age of an American Indian being 26 years. (Cameron 2001) Because they are a very small population it is extremely important to bring to light the issues that impact the preservation of the culture. In this paper I hope to tackle the topic of suicide inside the American Indian culture because if continued at this rate of prevalence the culture will indeed become endangered.

There are three aims for this research paper. The first aim is to examine the cultural factors that impact the state of mental health and mental healthcare for American Indians. The second aim is to further investigate how these factors explain the excessive rates of suicide within this population. Finally, third aim is to explore what possible prevention and awareness education is available for the American Indians concerning suicide. I will approach this paper by dividing it up into four important topics. First I will discuss how the combination of both the dominant culture and the American Indian culture impacts mental health within the population.

Next I will discuss the dilemmas that American Indians face while seeking mental healthcare. Also I will explain how both factors, mental health and mental healthcare play a vital role in the suicide prevalence. Finally, I will describe the treatments being utilized in effort to combat both the high rates of suicide and the inadequacies in mental healthcare. It is important to study suicide among these people not only because it impacts a large percentage of this small population, but also, because of their extremely small representation in the United States, there is not a sufficient amount of information known to determine the causes and provide effective prevention measures to ensure that these rates do not continue to increase.

Also because this is such a young population, the prevalence of suicide in the youth has become a major player in the extinction of the American Indian culture. To put this issue into context, the Indian Health Services 2001 study reports that the suicide rate of American Indians 15-24 is 2. 8 times higher than that of their non-American Indian counterparts. Additionally more than half of American Indian adolescents report being depressed. (Cameron 2001) Also the Indian Adolescents Health Survey shows that 20% of all American Indian girls have attempted suicide. The Conflict of Two Cultures Acculturation In the early twentieth century, American Indian children were sometimes forcibly removed to live with white families in order to shed their language, traditions, and become "civilized." The assimilation of American Indian children into a society that was unfamiliar and not their own impacted the tribal structure tremendously.

(Ecohawk 1997) A pattern that is still being seen today is that the "educated" children are becoming disconnected to the elders in the community. Children who have either voluntarily and forcibly been assimilated have lost the language and skills making it largely difficult to communicate with parents, grandparents and other relatives. (Ecohawk 1997). This one impact of history on the American Indian people is not unique. The larger society has played an important part in influencing the stresses put on American Indians. The culture has been repeatedly exploited as well as many attempts have been made to exterminate the tradition and heritage that still exists.

The topic of identity is a major issue for many American Indians, old and young alike. A major part of American Indians' history is made up of the continuous effort to change the culture through acculturation. As described by Cameron 2001, acculturation is the way an individual incorporates the values and traditions of a new culture into their currently held values and beliefs; this usually refers to an individual from a non-dominant culture. There are four different ways that American Indians deal with acculturation that affect their ability to seek out help for their mental illnesses. (Berry and Kim 1988; Cameron 2001) To be discussed further in the Seeking Help section, American Indians can respond in one of the following four ways: they can reject the dominant culture, totally assimilate, integrate while maintaining their own heritage, or de-cultura te (Cameron 2001). Although they are not limited to these four reactions, the overall embrace and influence of the dominant culture plays a large part in determining how an individual views himself and in the example of the school children, how an individual views his community.

Spirituality It is debated whether or not great spirituality plays an important role in suicide-related behaviors. On one hand we find in Ellison (1991) that strong religious commitments, as those found in many American Indian communities, are associated with greater happiness, a sense of life fulfillment, and a better ability to cope with trauma (coping theory). On the other hand, we also find that those religious commitments may cause stress especially in the case of American Indians, where many of their behaviors are "at odds with the values of the dominant culture." (Manson 2001). The resiliency and coping theory is utilized by prevention and intervention targeting suicide among American Indians, but scholars argue that perhaps one of the reasons the rates are continuing to rise is that when Indian individuals try to adapt their spiritual values and beliefs to contemporary society they are often met with scorn, distress, and conflict. Traditional healers are often preferred over traditional doctors for the reasons that they incorporate much spirituality in their treatment methods. In a 2001 study conducted by Manson, two thirds of American Indians who visited the country's largest primary care facility in Washington state said they employed traditional healing practices regularly.

(Cameron 2001) Dilemmas in Mental Healthcare Mental Health Counseling (Cultural Sensitivity) Because the mental healthcare facilities are limited in the isolated areas where many American Indians live, the only other options for treatment is located within the values and beliefs of another culture. With this issue, questions of whether counseling can be applied in a culturally sensitive and appropriate way from non-American Indians are asked. It is important that psychiatric and psychological counselors understand the traditions of the culture in order to suggest meaningful treatments. For example, Ecohawk tells us that in certain tribal clans there is a system of silence reserved for the most respected members, however often in treatment plans psychologists offer better communication as a goal to heal family problems neglecting the fact that silence is a part of the culture. He argues that, "It is extremely vital to have some understanding of tribal relationships to be able to differentiate social custom from actual pathology." (Ecohawk 1997) Supplementing our discussion in class during our segment on patient-doctor relationships, Cameron explains " In general, when the clinician and patient do not come from the same ethnic or cultural background, there is a greater potential for cultural differences to emerge. In particular, clinicians may be more likely to ignore symptoms that American Indians deem important, or are less likely to understand the American Indian's fears, concerns, and needs." (Cameron 2001) In the case of elders in the American Indian community, language can become a major barrier in their seeking help.

There are approximately 280, 000 American Indians that speak a language other than English at home. (USDHHS 2001) Because in many tribes, such as Navajo, there are no words for "anxiety" or "depressed" many elders who rely heavily on their tribal language are unable to communicate their symptoms and feelings. Mental Healthcare AccessabilitySeeking Mental Health Help Cameron explains the dilemma of ethnic minorities seeking healthcare as, "Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy and / or traditional healer), the pathways they take to get services, and how well they fare in treatment." Similar to other minorities in the United States, American Indians are less likely than whites to seek support for their mental illnesses. This apprehensiveness in seeking help is not only a result of the unavailability of treatment facilities, but as with other ethnic groups, the way in which American Indians seek help is influenced by the ways, "the culture interprets and communicates its individual, family, and community problems." (Cameron 2001) Not only do American Indians have their own values and beliefs concerning physical and mental illnesses, they also have to incorporate the values and beliefs of the dominant culture in which most of the treatment facilities are located. As mentioned earlier there are different ways that American Indians can react to the influence of the dominant culture that affects the way they seek help, this ranges from " readily and easily adopting the changes, rejecting them, or collapsing under the pressure." (Cameron 2001) Rejecting the dominant culture can force American Indians to seek help solely from other American Indians, however there are only 101 AI/AN mental healthcare providers per 100, 000 members of these populations leaving many individuals without treatment.

(Henderson 1998; Cameron 2001) Accepting the dominant culture either through assimilation or integration has more of a positive effect on seeking help because it allows the individual to combine the healing methods of both cultures. Finally, , or rejecting both cultures, further complicates the issue of identity and also aids the individual in refraining from getting help from anyone. Resources Besides the cultural dilemmas that American Indians face concerning the doctor-patient relationships, there is another additional component that hinders them from receiving the mental healthcare necessary: access. Most American Indians who live on reservations receive medical care from the Indian Health Services (IHS), however only those tribes recognized by the federal government are eligible for this benefit. According to Professor Troy Johnson, California State University, there are many tribes that have American Indian origins that are not considered "tribes" such as the Cherokees of north and south Alabama, the Nanticoke Association of Delaware as well as hundreds of others. For those American Indians who do receive the benefits of the IHS, the level of the quality of care is often is far from the level that was promised in the Indian Healthcare Improvement Act.

That act promises, " to provide the quantity and quality of health services necessary to elevate the health status of American Indians and Alaska Natives to the highest possible level and to encourage the maximum participation of tribes in the planning and management of those services." (Public Law 94-437) A major sub-group within the American Indian and Alaskan American Indian population that goes under served are the young and elderly. Although the suicide rates are highest among 15-24 year olds, according to Cameron (2001), specialized health services for these populations are limited because of the difficulties in recruiting trained specialists. Serious mental and social problems frequently go untreated because of the access ability to such serious intervention methods. Many vital elements of mental health treatments such as suicide prevention programs, and child abuse victim treatment are not available on reservations (Cameron 2001) Contributing Factors to the Prevalence of Suicide While many American Indians do not live on reservations, the incidences of suicide is very high for those who live on or very close to the reservations.

(Borowsky et al 1999; Stiffman 2004) From the demands and pressures that acculturation/ present on and off the reservations there are several risk factors that are abundant, helping trigger suicide-related behavior (including suicide, suicide attempts, and suicide ideation) such as alienation from family and community, mental and emotional problems, and alcohol and drug use (Grossman et al. 1991). The intersecting of dominant culture with American Indian culture influences many of the pre-cursors to suicide including personal feelings of alienation, anomie, helplessness, hopelessness, and despair. These feelings are some of the most common symptoms of depression, in which one-third to one-half of all patients seen by the Indian Health Service's mental health outpatient clinics are treated for.

Additionally it is proven that, "Overwhelming stress from rapid acculturation and loss of traditional identity often leads to a state of chronic depression." (Shore, Manson 1987; Tomren 1999) In attempt to maintain the balance between white social values and cultural beliefs, a feeling of alienation is very common among young American Indians. This alienation has the potential to develop into hopelessness and helplessness. The powerlessness and non-existence that hopelessness evokes is a strong precursor to suicide especially within a community that is regarded as isolated and unimportant... Additionally when there are limited options to finding support and treatment, the young especially exhibit feelings of helplessness further pushing them to suicide-related behavior. Prevention and Awareness Education American Indian and Alaska Natives often do not have the best exposure to top notch health care, but currently there are several programs that are being utilized to combat the issue of mental health and its correlation to suicide. The IHS recognizes that mental health plays a large part in American Indian suicides, noting that depression is the number one psychiatric problem among the population.

As a result IHS utilizes a crisis-oriented outpatient program and an emergency mental health program for outside clinic and hospital hours. Although offered to a limited region, there are five very successful programs that are located within the AI/AN communities as so to ensure cultural sensitivity and to target the individual sub-groups. The Indian Suicide Prevention Center targets at-risk youth who are in jail demonstrating one or more of the mental symptoms mentioned earlier. Also targeting the youth, the Natural Helpers program is utilized in selected school systems in order to screen and identify the certain students who are at risk for suicide-related behaviors. The Tohonno O'o dham Psychology Service, located in southern Arizona, is a mobile clinic that addresses the needs of those suffering from mental illnesses and offers routine screening for the young and elderly.

The last two programs are especially known to advocate for the research of suicide in under represented minority communities. The Zuni-Life Skills Development Curriculum studies the effect of community mentors and life skills preparation on AI/AN teenagers, while the Wind River Behavioral Health Program examines the effects of unemployment, drug, and alcohol abuse on mental health (APA). Conclusion Although the American Indians and Alaska Natives represent a small minority in the United States, they have had a large role in shaping past and present events in America's culture. Unfortunately, there is isn't adequate information known about this isolated yet diverse population and as a result a great challenge lies in the ability incorporate professional, social and cultural sensitivity with effective treatment methods. What is known about this high prevalence is that the emersion of American Indian culture into the dominant culture and vice versa has played a major role in not only the mental health of American Indians but also the ways they go about seeking help for their it. While it seems that there are sufficient intervention methods, the rate of suicides in this population has not decreased.

The lack of cultural competency as well as the limited dispersion of mental healthcare facilities has resulted in many American Indians turning away from the IHS and often resulting in suicide. The status of health and healthcare in the American Indian population is not a topic that can be quickly solved. For decades, American Indians have received poor treatment from the majority, however their self-preservationist culture has enabled them to survive despite their inaccessibility to quality healthcare. It is important that we keep studying this population in order to gain insight into ways of coping with their illnesses and illnesses that have high prevalence in other minority groups. Because the Indian Healthcare Improvement Act promises an equal quality and quantity of healthcare it is the duty of agencies such as the Human Health Services, the CDC, and the Community Suicide Prevention Center to continue to research in order to solve such issue as alcoholism, drug abuse, and obesity, all which have high prevalence in the American Indian community. 1.

American Psychological Association. Suicide: A Crisis within the American Indian Alaska Native Community. May 26, 1999. 2. Berry J. W.

, Kim. "Acculturation and Mental Health," Health and Cross-Cultural Psychology (1988) 207-236 3. Borowsky I. W.

, Resnick M. D. , Blum R. W. "Suicide Attempts Among American Indian and Alaska Native Youth: Risk and Protective Factors," Archives of Pediatric and Adolescent Medicine 153 (1999) 573-5804.

Garrotte et. al "Spirituality and Attempted Suicide Among American Indians, " Social Science and Medicine 56 (2003) 1571-1579 5. Grossman D. C.

, Milligan C. , Demo R. A. " Risk Factors for Suicide Attempts among Navajo Adolescents," American Journal of Public Health 271 (1994) 845-8506. James H. Shore, Spero M.

Manson, Joseph D. Bloom, George Keepers, Gordon Neigh, " A Pilot Study of Depression Among American Indian Patients With Research Diagnostic Criteria," American Indian and Alaska Native Mental Health Research 1: 2 (1987) 4-157. James H. Shore "American Indian Suicide: Fact and Fantasy," Psychiatry 38 (February 1975) 3886-3891 8. Jeanette Johnson and Mark Cameron "Barriers to Providing Effective Mental Health Services to American Indians," Mental Health Services Research 3: 4 (2001) 215-222 9. Manderscheid R.

W. , Henderson M... J. "Mental Health United Stated 1998," Center for Mental Health Services (1998) 10. Marlene Ecohawk, " Suicide: The Scourge of Native American People," Suicide and Life- Threatening Behavior 27: 1 (Spring 1997) 60 11. Middlebrook D.

L. , Le Master P. L. , Beals J. , Manson S. M.

" Suicide Prevention in American Indian and Alaska Native Communities: A Critical Review of Programs," Suicides and Life-Threatening Behavior 31 (Spring 2001) 13212. Stacey Freedenthal and Arlene Stiffman "Suicidal Behavior in Urban American Indian Adolescents: A Comparison with Reservation Youth in a Southwestern State," Suicide and Life Threatening Behavior 34: 2 (2004) 180-17113. Troy Johnson and Holly Tomren "Helplessness, Hopelessness, and Despair: Identifying the Precursors to Indian Youth Suicide." American Indian Research Journal 23: 3 (1999) 287-30114. USDHHS 2001- Surgeon General's Report on Mental Health: Culture, Race, Ethnicity.