Native American Mental Health: An Introduction and Invitation

May 12, 2023

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00:04All right, The way we're going
00:05to do is I'm going to take the
00:07first half of the presentation,
00:08and my colleague Dr.
00:10Beitel will be doing the second part.
00:12But why don't we start off
00:13with me sharing my screen?
00:16Yeah.
00:23All right. I'd like to begin
00:25with his land acknowledgement.
00:27Yale University acknowledges that
00:28indigenous peoples and nations,
00:30including Mohegan,
00:31Mashantucket Pequot, Eastern Pequot.
00:34Scatticoke, Golden Hill,
00:36Progressive, Niantic,
00:37and the Quinnipiac and other
00:39Algonquin speaking peoples have
00:40stewarded for the generations the
00:42lands and waterways of what what
00:44is now the state of Connecticut.
00:45We honor and respect the enduring
00:47relationship that exists between these
00:49peoples and nations and this land.
00:51All
00:54right, Well, welcome to our Native American
00:56Mental Health Program presentation.
00:58It's housed in the Child Studies Center,
01:00Yale School of Medicine.
01:01I'm Chris Cutter.
01:02My relations are out of the
01:04three ability of Crimes Nation,
01:05North Dakota. Some years ago,
01:07I served as Assistant Dean in
01:08Yale College and the Director
01:10of the Native American Cultural
01:11Center for the University.
01:15I'm joined by Mark Whiteell,
01:16my former post doctoral mentor
01:19now colleague who codirects our
01:21Clinical Research treatment program.
01:23We are delighted to welcome you
01:25and provide some background on
01:27diverse array of Native people
01:29living in the United States.
01:30And invite you to connect us to
01:32explore possible collaborations.
01:37We hope the Native American Mental
01:39Health Program becomes a conduit for
01:41the generation of culturally sensitive,
01:44sophisticated, and clinically useful
01:46research within for Native people.
01:48We're deeply committed to mentoring our
01:50Native students at all levels of training,
01:52from undergrads to post resident fellows.
01:57So I'll begin with this.
01:59The term Native American or American Indian.
02:02So this refers to a large and
02:04diverse group of people who descend
02:06from those first inhabitants of
02:07what is now called North America.
02:10In the introduction of her book titled
02:12Mental Health Care for Urban Indians,
02:14Doctor Witco notes there have been
02:16many discussions among Indian and non
02:18Indian people as to which name is most
02:20appropriate or politically correct.
02:23Depending on whom one asks,
02:25one will get two very different reasons,
02:27both of which are valid.
02:29In addition,
02:30the indigenous peoples living in Presentday,
02:32Alaska and Hawaii are referred to
02:34Alaskan Vedas and Native Hawaiians,
02:36respectively.
02:39While various terms are permissible,
02:41there are definite cultural and
02:43geographic use of preferences.
02:45In fact, no term for this group of people
02:48is free of problematic associations.
02:51When working with specific individual group,
02:54it's just best to ask
02:56which term is preferred.
02:57Often preference is.
02:58To be identified by tribe or village.
03:03We will also be crossing disciplinary
03:05boundaries by using client and patient and
03:08counseling psychotherapy synonymously.
03:12Finally, we will make a distinction
03:14between modern medicine that's
03:16practiced in universities and
03:18hospitals and native medicine that's
03:19practiced by tradition healers.
03:27Recent US Census data, 2020.
03:31Indicates that 9.7 million people
03:33or 2.9% of the total population
03:36identified as American Indian
03:38or Alaskan native tribes.
03:40I'm sorry Alaskan native
03:48so alone in or when we say
03:50AIAIAN for short by the way.
03:52So that's in alone or in
03:54combination with another race.
03:56There are currently 574 federal
03:58recognized American Indian Alaskan
04:00Native tribes and villages in the US,
04:03representing tremendous cultural,
04:05linguistic and geographic diversity.
04:08Due in part to the federal relocation
04:10policies of the last century,
04:12most Native people, over 75%,
04:15now live in urban centers
04:16rather than on reservations.
04:23Who is Native American?
04:25Okay. So it's a loaded one.
04:27Native American affiliation
04:28has been determined by
04:30biological and cultural factors.
04:32So blood quantum or percentage
04:35of Indian blood, quote UN quote,
04:38must be demonstrated by what
04:40is called a CID card or
04:42certificate of Indian blood card,
04:44which functions as a proof
04:46of tribal and Roman.
04:48This approach along with the use of.
04:50Physical features.
04:51So for example,
04:53does someone look like your
04:55stereotypical native person?
04:56Is rooted in early understandings of
04:59race laden with ideas from eugenics.
05:05When referring to culture, though,
05:06a helpful focus would observe the
05:09characteristic characteristic
05:10ways of thinking, feeling and
05:12behaving of the identified group,
05:15along with their rights,
05:17respective rights, rituals, myths.
05:24The increased risk for
05:26morbidity and mortality.
05:29So the most highlighted general and
05:31mental health disparities among Native
05:33American people are type 2 diabetes,
05:36substance abuse, and suicide.
05:37Also, unintentional accidents
05:38due to the significantly higher
05:41rates of prevalence compared to
05:42the rest of the US population.
05:45So in 2007, 2009 it's being updated.
05:48This is the most updated report on to
05:53I HSIHS means Indian Health Services.
05:56On this one.
05:57The age adjusted death rates for the
05:59following causes are considerably higher
06:01than those of the US are all races in 2008.
06:04So let's do some following comparisons of
06:07American Indians and Alaska Natives age
06:10adjusted compared to the rest of the US.
06:12So we have alcohol related deaths,
06:14it's 520% greater, chronic liver
06:18diseases and cirrhosis 368% greater,
06:21less of the US population,
06:23diabetes 177% greater.
06:26Typically type 2,
06:27unintentional injuries 141%
06:29greater and suicide 60% greater.
06:38Doctor Diller. Psychiatrist working
06:41with native people back in the 1970s
06:44generated an early list of cultural
06:46differences between the quote UN
06:48quote classic Western psychiatrist
06:50and Native American patients.
06:53The general theme involves
06:55differences between individual
06:56and collectivistic orientations.
07:01Let's take a look at that
07:04and we move on to Garrett.
07:08Garrett provides another version
07:10of this list with a similar
07:13distinction between individualistic
07:14and collectivistic stereotypes,
07:16a little bit more modernized.
07:20I'm
07:26going to share with you what we tell
07:29our undergraduate students when we
07:31frame these very sensitive issues.
07:33We say, remember, humans are fallible.
07:37We are cognitive misers.
07:39Thinking about differences can be stressful.
07:43Furthermore, I'd like to point out that.
07:45All human stereotype.
07:47It's a mental shorthand we we all share.
07:50Sometimes you can get us in trouble,
07:51particularly if we prejudge.
07:53Some people are very quick to
07:55prejudge without testing reality.
07:57Unfortunately,
07:57some people act on the prejudice
07:59and behave in racist ways.
08:06Categories. So I'd like to point
08:09out some problems with thinking in
08:11terms of either or or us versus them.
08:14Stereotypes. Nature.
08:18Itself resists simple categories.
08:20For example, in distinguishing
08:22an animal cell from a plant cell,
08:24we have a problem between group similarity.
08:29In other words, there's overlap,
08:31and we have a problem of
08:33within group heterogeneity,
08:35which is to say people or things
08:37within a group can be highly variable.
08:45So the dimensional models improve on
08:47these on categorical models because
08:49they capture more human complexity.
08:52Specifically, they allow for the
08:54possibility of biculturality.
08:56In other words, a person could be high
08:57on native affiliation, for example,
08:59and also high on white affiliation,
09:01or any combination thereof.
09:09Acculturation is an interesting framework,
09:13so one of the popular conceptual
09:15frameworks is to think of native
09:17people as either traditional.
09:18Marginally assimilated by cultural
09:20assimilated to dominant culture or pan
09:24traditional pan traditional people,
09:26for example, are assimilated Native
09:28American peoples who have made the
09:30conscious choice to return to the old ways.
09:40Interventions for American Indian
09:41communities are too often focused
09:44on one individual pathology,
09:46to neglect of the general human
09:48and cultural specific strengths
09:50and focus on Western medicine.
09:52To the exclusion of indigenous
09:54cultural beliefs and practices.
09:56So in fact the cultural
09:58self can be quite healing.
10:00We focused, we should be focusing
10:03on strengths as much as weaknesses,
10:05and that's tended to be the
10:07approach that Doctor Patel and I
10:08take is focusing on the strengths.
10:10Social support and self esteem are both
10:13protective against suicidal ideation
10:14in American Indian adolescents.
10:16For example.
10:17Some evidence suggests that
10:19increased levels of.
10:20Hope and optimism are related to
10:22reduced levels of suicidal ideation,
10:24so having a sense of belonging was
10:27inversely associated with suicidal
10:28ideation but unrelated to attempts.
10:39Commitment to a Pan Indian spiritual
10:42orientation was associated with
10:44reduced self reported suicide attempts
10:46in one study, the authors define.
10:48Spiritual orientation with an 8
10:49item self important questionnaire
10:51designed for that purpose.
10:52So some of the these items are there
10:56is balance and order in the universe.
10:59I am in harmony with all living things.
11:01I feel connected with other
11:03people in my life.
11:04Follow the spiritual path,
11:06describe my by my tribal tradition.
11:09When I need to return to balance,
11:12I know what to do and I feel
11:14like I am living the right way.
11:17I give to others and receive
11:18from them in return,
11:19and I'm a person of integrity,
11:26so our native communities nearby.
11:30The provision of education of
11:33Native Americans is not stipulated
11:34in Yale's charter as it is in the
11:37charters of Harvard and Dartmouth.
11:39In fact, it took more than 200 years for
11:41Yale to graduate its first native student.
11:43His name was Henry Rowe Cloud and
11:45he's a member of the Pochuck Nation
11:47of Nebraska and he went on to work
11:49tirelessly on behalf for Native peoples.
11:51In recent years,
11:52Yale has done an excellent job in
11:54recruiting and retaining native
11:56students and has developed an impressive
11:58Native American Cultural Center,
11:59which I was very proud to be
12:02part of when development.
12:03So we all we have several groups
12:05out of the Native Cultural
12:06Center and the native community,
12:08the Yale group.
12:09For the study of Native America boasts a
12:12dozen faculty affiliates and many more
12:14postdoctoral and graduate students.
12:19For our program,
12:19our Native American Mental Health Program,
12:21we're quite proud of developing its
12:23first of its kind here on Yale campus.
12:24And not only would it be founded program,
12:27but we also teach a course for
12:29Yale undergraduates titled
12:30Native American Mental Health.
12:32And it's our hope between the
12:34undergrads and the graduate students
12:36we mentor it to increase the pipeline.
12:38For clinicians in the field of mental health,
12:40which is desperately needed.
12:43All
12:46right. So I'd like to take this time
12:52to introduce some of our fellow native
12:54clinicians and collaborators that help
12:57with this mission of increasing care
12:58and effectiveness of mental health
13:00interventions in Indian country.
13:01So we have and we're very lucky
13:03to have Linda Larva.
13:05She's a Yale graduate herself at
13:07the doctoral nursing program.
13:09She's a lifetime chief of the Michigan tribe.
13:11And also have Carla Knapp,
13:13a very close colleague of ours.
13:15She's the president of the Native
13:17Services division of the Boys and
13:18Girls Club of America, the largest
13:21Native youth serving organization.
13:23I think in the world.
13:26We have Wamney, evil woman, Arrow.
13:28She's the director and actually former
13:30director of Fort Belnet Social Services.
13:33She was when we made the video.
13:35She's moved on to a very similar field.
13:38And we also have our very
13:40own Stephanie Gilson,
13:40our child,
13:41child and adolescent fellow at
13:43the Yale Child Study Center.
13:45So go ahead and hit lay on this.
13:51A wig woman welcome Natti you is
13:53some squama time. What's hosh?
13:54My name is Chief Many hearts.
13:56Lynn Mullerba of the Mohegan tribe.
13:58And the reason I'm called the chief
14:00Many hearts is very personal to me.
14:02Our medicine woman stood the name upon me.
14:05My earliest career was as a critical care
14:07nurse and then as a hospital administrator,
14:10and I specialized in cardiology
14:12and critical care.
14:13And so when I became chief,
14:15our medicine woman said, well, you can't.
14:17Not take a Mohegan name.
14:19Now you've delayed, you've waited.
14:21You you know you dithered about about this.
14:23Now you actually have to take a Mohegan name.
14:25So she said I'm going to name you And
14:28so she said I'm going to call you chief
14:31many hearts because you've held many
14:33hearts in your hands in the past and now
14:35you hold our hearts in your hands as cheap.
14:38And so I thought that was the perfect name.
14:40I proudly carried that forward some
14:42squad is the Mohegan word for female
14:45chief because of course tribes are very.
14:47Egalitarian.
14:48And so women have always played large
14:51leadership roles in their communities.
14:54And so some squad translated
14:55me as rock woman.
14:57So who wouldn't just love to have
14:58that as your title, Rock Woman.
15:01And so I'm,
15:02I'm pleased to offer a few comments today,
15:04and I know they're supposed to be brief,
15:06but one of the things that was really
15:09important to me is as I moved away from
15:13actual clinical care and into tribal
15:15government and tribal governance.
15:17I always believed that it was my
15:19job to advocate for the best of
15:21all of the Indian country,
15:22not just for our own tribal people.
15:24And so I've been able to work at
15:26the national level to make sure that
15:28they're we're holding the United
15:30States accountable for their trust
15:32and treaty obligations to tribes.
15:34And we exchanged.
15:36Land and natural resources which the
15:39United States is now founded on in
15:42exchange for healthcare and and general
15:45welfare and education for our tribal people.
15:49So when Yale decided that they would
15:52offer a doctor of nursing practice in
15:55policy and leadership even though.
15:57You know,
15:58I'm was this close to collecting
15:59Social Security.
16:00I thought,
16:00you know,
16:01I really want to do this program because
16:03it will wrap up my earlier career
16:05with the work that I'm doing now and
16:07maybe I can make a big difference.
16:09And so I I applied for the doctor
16:12of nursing practice program and
16:15and also I thought,
16:16Gee,
16:17maybe I should have cared a bit more about
16:19what my grades were for my master's program,
16:21never thinking that I would apply for yet one
16:24more educational opportunity and what I did.
16:27As I explored budget and funding
16:30for Indian Health Services and it
16:32was really important work that we
16:33did and I'm proud to say that some
16:36of the work that we're doing now
16:38and some of the legislation that
16:40is being considered now
16:41is a direct result of that work.
16:43So we engaged the Office of
16:45Management and Budget, White House.
16:48Council on Native Americans,
16:50the director of Indian Health Services,
16:53tribal leaders, tribal organizations,
16:54and we really did a deep
16:56dive into the budget, so.
16:59The important take away for that
17:01is that you know we should always
17:03offer our time and talents when we
17:05have them and we should always raise
17:07our voices when we are asked to.
17:09And I grew up a very shy kid,
17:11but I really very early on that our
17:14work is really important and we need
17:16to advocate for the whole of Indian
17:18country and for the best of Indian country.
17:21Our social determinants of health
17:23are abysmal despite the fact that.
17:25We are the only people in this United States
17:28that has a treaty obligation for healthcare.
17:32And yet all the other programs for healthcare
17:34are on the mandatory side of the budget,
17:36such as Medicare,
17:37Medicaid and Veterans Affairs.
17:39And Indian Health Services is on the
17:41discretionary side of the budget,
17:42meaning it could be taken away at any time.
17:45So to me,
17:46that's backwards and we've been
17:48working to correct that.
17:49The other thing that,
17:50you know,
17:51I've been asked to speak a little
17:53bit about is how important the Native
17:55perspective is to taking care of mental
17:58health care needs of our people.
18:00And what's really important about tribes,
18:03how we're organized and how we
18:05think about the world in general
18:07is that everything is connected.
18:08So we don't silo our programs and
18:11our services to our tribal citizens
18:13in one bucket.
18:14We think about health in a very
18:17global perspective,
18:18in a very holistic perspective.
18:20That's not the way the federal
18:22government operates.
18:22So if you happen to be heavily grant funded,
18:25that's not the way you're going to
18:27necessarily pursue funding, but what?
18:30What we think about is the fact
18:32that everything is connected.
18:33Our environmental health,
18:34our physical health, our social health,
18:37our cultural health,
18:39and our behavioral health.
18:40So as we design and develop programs
18:42for the benefit of our tribal people,
18:45we try to connect all of those things.
18:47And there's been so much research
18:49that shows us that.
18:50Tribal children who are connected
18:52to their culture get a very
18:54protective benefit from that.
18:56So I challenge all of the people who
18:59are charged with designing A behavioral
19:02health programs to really infuse
19:04culture into everything that they do.
19:07And we've found that that has been a
19:10very successful way to approach the
19:12health and and the services and the
19:14wellbeing of all of our citizens.
19:17We respect differences and you
19:18notice that I talked a little bit.
19:21About environmental health,
19:22we don't see the world as inanimate.
19:25All of our language describes the
19:28environment, it describes the weather,
19:30it describes nature.
19:31Trees, animals, all is animate.
19:34That's protective as well,
19:36because you can't hurt Mother Earth if
19:38you believe that Mother Earth is animate.
19:41And if you think about how
19:43environment impacts our mental
19:45health, just being out in nature.
19:48Is such a wonderful way
19:51to infuse a good feeling,
19:53to infuse help to overcome perhaps
19:55some anxiety that you're feeling.
19:57So as we think about mental health,
19:59we have to think about it more like tribes
20:02have always traditionally thought about
20:04health in that very global, holistic way.
20:06And ceremony is a piece of that as well.
20:10When we participate in ceremony,
20:12we're connecting back to our ancestors.
20:15So we are also leaving footprints on the
20:18path for those that we have yet to meet.
20:20That's a very different way of working,
20:22looking at the world and
20:23working in within the world.
20:25And so I encourage everyone to think
20:27about that strongly and to think
20:29about when you're designing programs.
20:34Who you might bring to offer that
20:37perspective? And then lastly,
20:38the other thing that I've been asked
20:40to speak about is research and is
20:43it beneficial to native tribes.
20:44One of the things that I've been
20:47very engaged and I'm on a Tribal
20:49Advisory Advisory committee for
20:51the National Indian, excuse me,
20:53I'm not the National Indian Health Board,
20:55but National Institutes of Health.
20:57And they talked a lot about genomic
21:00studies and it really prompted me to
21:02think about research in a different way.
21:05And so we at Mohegan now have a
21:07tribal data sovereignty review board.
21:10Anytime there's research that's
21:12being proposed,
21:13it has to come through this review
21:15board and we have to think about it.
21:17Does it stigmatize?
21:18Is it really looking at tribes
21:21without an indigenous lens?
21:23Are there indigenous scholars
21:25that are doing the research?
21:26Is there benefit to our tribal community?
21:29Where will this get published?
21:31How will it get published and will we
21:33be able to have some control over,
21:35you know, all of those things?
21:37Because we know that in the past there's
21:40been very stigmatizing research for
21:41Native people and we want to avoid that.
21:44We believe that research is very important,
21:47but we want to make sure that
21:48if we're going to.
21:49Engagement,
21:49research that there actually
21:50is a benefit to our community,
21:52that it's not just for this ephemeral
21:55knowledge that really won't touch
21:57our tribal people and won't enhance
21:59the wellbeing of our tribal people.
22:01And as we think about research,
22:03one of the things we've looked at
22:05is genomic studies and how does that
22:08impact tribes and how do we protect
22:10confidentiality if you are a small tribe?
22:13And what do you think about consent for
22:16research if a tribal citizen is consenting?
22:19For research,
22:20does that automatically equal the
22:21consent of the tribal community?
22:24So there are many ways that we
22:25need to think about research.
22:26And I do believe that there are
22:28ways that we can accomplish good,
22:31solid research that will enhance the
22:33well-being and lives of our Native people.
22:36We need to be careful about how that happens,
22:39but we always want to make sure that that
22:42research refers to an indigenous lens.
22:44And so I'll leave my comments there.
22:46Thank you for allowing me to speak today.
22:49Hi, my name is Carla Knapp,
22:51the National Vice President of Native
22:54Services for Boys and Girls Club of America.
22:57I'm a proud tribal member of the Tenobska
22:59Indian Nation and child of beer equipment.
23:02I am married to one of our tribal members
23:05and the mother of two amazing children,
23:07a 31 year old son and a 12 year old daughter.
23:11It is with their support that I'm able to
23:14follow my dreams and providing resources
23:16and opportunities for our Native youth.
23:19It is my honor and privilege to
23:21lead the Native Services team at
23:23Boys and Girls Club of America.
23:25Together with a team of seven passionate,
23:28purpose driven colleagues representing
23:30several several different tribal nations,
23:33we partner with tribes across the nation
23:35to bring clubs to American Indian.
23:37Alaskan, Native American,
23:39Samoan and Hawaiian communities.
23:41Currently, there are more than
23:43200 Native Boys and Girls Clubs,
23:45representing nearly 150 tribes who
23:49collectively serve over 120,000 youth.
23:52Our clubs support academic success,
23:55providing positive adult role models,
23:58feeding programs, health and life skills,
24:01character and leadership development.
24:03And most importantly,
24:04they keep our traditions alive
24:07by embedding Indigenous cultural
24:09components throughout the club day.
24:11Our culture is a way of life,
24:12and our culture as Native people
24:14shows up in the values, our beliefs,
24:17how we gather, how we eat,
24:19how we learn,
24:20and so much more. These
24:22traditions are so important to
24:24pass on to our young people who
24:26will carry our culture forward.
24:29In Indian Country,
24:30Native clubs meet the needs of
24:32communities in our direct reflection
24:34of the people they serve.
24:36As a national organization,
24:38we believe every child deserves a
24:41great future and we're committed to
24:43building on their strengths and skills
24:46to realize that future within them.
24:48Across the nation,
24:49youth and different communities
24:52experience drastically different
24:53circumstances and in Indian Country,
24:55a history of historical trauma.
24:58Along with many other factors contribute to
25:01challenges especially acute for Native youth.
25:04But when young people have access to
25:07programs that focus on academic success,
25:10leadership skills,
25:11and the resiliency critical to graduating
25:13high school and planning for the future,
25:16they can succeed.
25:19Since every tribal community is unique,
25:21we adapt our national programming that so
25:24that it speaks to all Native communities.
25:27Recognizing the beauty and diversity
25:29within our tribal nations.
25:31From there, tribes can customize youth
25:34programming and projects even further,
25:36weaving in their own traditions and culture.
25:40But the most critical role plugs on
25:43Native lands provides is consistency.
25:45They're open year round,
25:47five days a week,
25:48and staffed by caring mentors who
25:51understand what it needs means
25:53to be a Native young person.
25:55Family stability is deeply important
25:57in the life of a child and it's
26:00especially important for Native
26:02youth to know their club is their
26:05extended family and it's offerings,
26:07quality programming,
26:08traditions and culture,
26:10And of course fun is always
26:12there to help nurture resilience
26:14for our Native youth to thrive.
26:17The Boys and Girls Club of America.
26:19We respect and honor the right of Native
26:22people to control their own futures.
26:25Native people know their communities
26:26better than anyone else and they've been
26:29building their own solutions for centuries.
26:32As a national organization,
26:33I'm pleased to say that in 2022
26:36we'll be celebrating 30 years of Boys
26:39and Girls Clubs in Indian Country.
26:42The Native Services team enhances
26:44our ability to build and sustain
26:47collaborations with tribal leaders
26:49and stakeholders,
26:50provide professional development and
26:52networking specific for Native Clubs.
26:55Strengthen Native youth cultural identity
26:57through those customized programming.
26:59When you feel that sense of identity,
27:02connection and belonging,
27:03we can drive outcomes that
27:05will make an impact for youth.
27:07Boys and girls.
27:09Club of America and Native Services has
27:11developed a powerful growth strategy
27:14to expand opportunities for opening
27:16new Native Boys and Girls Clubs,
27:18ensuring that all Native youth now in
27:21the future will achieve their dreams.
27:23While allowing our Sovereign nations
27:25to retain a sense of ownership,
27:27buy in and direct access to information
27:30and support from the Native Services team,
27:33as we believe every Native youth
27:35and every Native community deserves
27:38the Boys and Girls Club.
27:40Thank you for allowing me to share the
27:43amazing work of the Native Services
27:45Team and the 216 Native Clubs who will
27:47do whatever it takes for Native youth.
27:53On at Tabor Dash Day,
27:56My name is Stephanie Gilson.
27:58I am Dakota Minwukaton Sioux,
28:01originally from Minnesota Macanche,
28:03also known as Minnesota.
28:05This is actually my tribal homeland.
28:08That's where the Dakota
28:10creation story takes place.
28:12And I am really fortunate to be here
28:15with you all during this grand rounds
28:17today where we are thinking about how
28:20to decolonize institutions and what it
28:22look like to partner with indigenous
28:25tribes during this indigenous day.
28:28And I also want to acknowledge
28:31that I am on Quinnipiac lands.
28:33This is a Connecticut in general.
28:36There is multiple tribes here who
28:38soured this land for hundreds of years
28:41prior to the arrival of Columbus.
28:43I am also a child adolescent
28:45fellow here at Yale.
28:47I completed my adult training as well
28:49as a public psychiatry fellowship in
28:51the Yale Department of Psychiatry.
28:53But I think more importantly,
28:54I'm a community member.
28:55I'm a daughter, I'm a sister,
28:57I'm a partner,
28:58and I'm a first generation college student.
29:01My mother struggled with alcohol
29:04use disorder and houselessness.
29:07You know,
29:08my grandparents went to boarding
29:10school and experienced a lot of
29:12what we call in the research papers,
29:15historical trauma, cultural loss,
29:18historical cultural losses.
29:20But like many Indigenous communities,
29:22I was raised by extended family
29:24and by aunties and.
29:26I was really fortunate to go to the
29:29University of Minnesota for medical school.
29:31It's one of the ones where we
29:32call the grade eight.
29:33We see there's eight medical schools
29:35in the country that prioritize
29:38admitting indigenous students,
29:40but also providing the structure and
29:43support by having indigenous people
29:45on staff and by helping them with the
29:49disconnect between medical education
29:51or academia and indigenous culture.
29:54And while there,
29:55I was really fortunate to work with a
29:59research group led by Melissa Walls,
30:01which is now under the Johns Hopkins
30:03and Upper American Indian Health and
30:06still really fortunate to be involved
30:08and working with these Native communities.
30:11You know the key to working with
30:14Native communities is community based,
30:16this is Pretoria Research or
30:18CDPR and really dedicating.
30:20Time and energy into knowing the
30:23tribes and knowing what they want
30:25and what we can help them with,
30:28if they even want our help,
30:29and especially with these
30:32big academic centers.
30:33And I think we have to be mindful
30:35of the harm that we've done to
30:37these communities in the pastor,
30:39do you know doing helicopter research
30:41or or a lot of the wrongs that have
30:45been done to these communities, so.
30:48Well,
30:48during the pandemic,
30:50we heard from our communities in the
30:52Midwest that they actually wanted
30:54to focus more on holistic healing
30:56and how can we provide some support
30:59for them during this pandemic.
31:01And so we ended up sending out holistic
31:05Wellness boxes to our community
31:07members that included wild rice,
31:09sage, some teachings from elders.
31:11A book about COVID for kids that was
31:15actually written by an an an Edition
31:17author Victoria O'Keefe and we also
31:20met with our frontline workers.
31:22Twice a month of frontline
31:24mental health workers who are
31:25really out there doing the
31:27daytoday work with our communities.
31:29We've also done some research looking
31:31at the impact of the foster care
31:34system that is still happening today,
31:36especially in in Minnesota,
31:38and thinking about the Indian Child
31:41Welfare Act that's currently being
31:43challenged in the Supreme Court that
31:45was passed in 1978 to make it so.
31:49If indigenous children can't be removed
31:52into the foster care system in place
31:54with non indigenous families, right,
31:56that's another way of cultural loss.
31:58That's another way of erasing
32:01indigenous people and their culture
32:04and thinking about historical trauma,
32:06relocation, boarding schools,
32:08like I mentioned,
32:09these things are still happening today.
32:12Like the Indian child welfare
32:14being being challenged,
32:15the Line 3 in northern Minnesota
32:18is an oil pipeline actually going
32:20through illegally from Anishinabe
32:23land through the only place in the
32:25world where wild rice grows naturally.
32:28And still operating today.
32:29And so I think that's one of the
32:32biggest things that people don't
32:33feel like they have the time to
32:36dedicate to develop relationships,
32:37finding things that are in the
32:38news and supporting the cause,
32:40supporting Line 3,
32:41supporting the fact that the Indian
32:43child welfare is being challenged
32:45in the Supreme Supreme Court.
32:47And I think that in general we have
32:53experienced as indigenous people so much.
32:57Adversity and so much continued
33:01attempt at a racer and genocide.
33:05But I want to leave you all with
33:08the fact that despite all that,
33:10we are still here.
33:12We are so incredibly resilient and
33:15we are using our traditional ways
33:20to continue to continue to thrive.
33:24But Covid's a really good example of that.
33:27And how we continue to use our
33:31traditional knowledge to be able
33:34to fight the pandemic.
33:37So I appreciate you all having me
33:39here today and I hope this was a
33:42great grand rounds that may I go make,
33:47which thank you
33:49humble Weshte, my name is Eagle Arrow.
33:53I'm an enrolled member of the ANI Nation
33:55on the Port Bellnum tribe in Montana.
33:58I have a degree in mental health
34:01counseling and it's a Master's St.
34:04My job title is the Director
34:05of Social Services,
34:06which encompasses Child Protective Services,
34:09Adult Protective Services,
34:11ICWA, the domestic violence
34:13program in the batters program.
34:17And if you're not familiar with ICWA,
34:19it's the Indian Child Welfare Act, which.
34:22And which is all of our native children
34:25that are spread out from across the
34:27country and even across the world.
34:29If they have ties to our reservation,
34:32then we seek out that they maintain
34:34contact with our reservation.
34:36And perhaps we try to find placement
34:39for them with a blood relative who
34:42is on the reservation if they're
34:44not in a place that is able to
34:48take care of their needs.
34:50And for Bellnap, there are several needs
34:52of the children on the reservation.
34:54Currently,
34:54we do lack a lot of resources for them.
34:58The mental health counseling,
35:00although we are enhancing programs,
35:02it's still far from where it needs
35:04to be because we're so rural.
35:06We do have telemedicine,
35:08telehealth, but because of culture,
35:10it makes it very difficult to see
35:13and identify what's really going
35:15on with the child because.
35:17Nine times out of 10,
35:18they're not going to talk to
35:19people that they don't know,
35:20they're not comfortable with
35:21and they're not familiar.
35:22They have no, you know,
35:24face to face.
35:25So it makes it uncomfortable for
35:27them and that is feedback that
35:29I've gotten from the kiddos.
35:31Secondary is we don't have
35:34a placement for them.
35:35When they do need a higher level of care,
35:38we're faced with quote UN quote
35:40farming them out and that has caused.
35:45Trauma on so many levels,
35:47but it's not only trauma for the kids,
35:49it's also trauma for the community.
35:51Because this is historically one of the
35:54worst traumatizing experiences that
35:56we've ever faced was when children
35:58were removed from the reservations
36:00and put into boarding schools.
36:02So similarly,
36:03it is continuing to affect and
36:06impact our people almost the
36:08same when they use that term,
36:11farming them out.
36:12And so because we don't have
36:15facilities here that can boredom
36:17or children who are suicidal,
36:20who are dealing with depression and
36:23acting out because of reactive attachment
36:26disorders or oppositional defiance.
36:30And this is either due to
36:32historic the history of trauma or,
36:35you know, the families not being
36:37engaged the way that they should.
36:40Then we have no place to put them
36:43and we are forced to put them in
36:45a place that can maintain their
36:48safety and also give them the
36:50therapeutic interventions also.
36:52Another is that although we feel
36:55like racism has come to an end,
36:58I had an experience with a child
37:01who was punished for speaking our
37:03language and when that happened,
37:05it not only caused an uproar in
37:08our community or our council.
37:10But I literally had to fly across
37:13the country and go into the boarding
37:15school and see what was happening there
37:18because I thought we were above that.
37:21But unfortunately, I can't control
37:24what's happening within those places.
37:26So because we lack those services here,
37:29when we put kids in foster homes,
37:31when we put them in schools,
37:33when we put them and we in
37:35therapeutic boarding facilities,
37:37it's hard to say.
37:39How they're being treated,
37:41if they're having that respect in the
37:44cultural and their cultural identity
37:47and how they're able to identify with
37:50the people that are teaching them.
37:53So this,
37:54this seems to be one of our largest meaning
37:56on the reservation that we're lacking,
37:59but it's just not our reservation.
38:01I'm going to speak,
38:03it's for all many reservations
38:05provided that I've worked with very a
38:07lot of them throughout my years and.
38:09Not only as a social services director,
38:12but also as a counselor in Arizona
38:17on different reservations,
38:19Social services has a large task
38:25and taking care of children.
38:27And it's not just because,
38:29you know, we have so many cases,
38:32but to one case manager.
38:34We do have around 42 to 3045 cases.
38:37And that's a lot asking of anybody.
38:42But I'm going to tell you that what we
38:44do well is that we love our children.
38:47I all of my social workers,
38:49they take the shirt off their back for them.
38:51And because of that love and their efforts,
38:54they go above and beyond for the children.
38:56And I'm going to say some of
38:58our children have aged out,
38:59but they call us to this day
39:02when they need something,
39:03when they need to confide in us,
39:04when they need support.
39:06And unfortunately,
39:07we do have a high turnover rate
39:09because of the stressors of the job.
39:11But I'm going to say that no matter what,
39:13the turnover rate isn't because of,
39:16you know,
39:16they don't the love for the children
39:18or the love for the community.
39:20The turnover rate is because it's really
39:23difficult to work in this position.
39:26And this is worldwide, C, PS:,
39:28has the highest turnover rate.
39:30Adult Protective Services.
39:32We can't control what's happening
39:35in our community and we will.
39:36Can't control hardly anything
39:38besides how we respond to the chaos.
39:42It becomes overwhelming and I'm
39:43going to say there isn't one person
39:46who has left this department
39:47that didn't have
39:48utmost love and integrity and respect
39:51for these children and our community.
39:53And that is what social service
39:55is really is about Here.
39:57Our development is only part of it,
39:59but the the love and connection
40:02that we have is phenomenal.
40:13Okay with that, I'd like to get it over.
40:16Give it over to Doctor Beitel.
40:24Thank you. I'd like to tell you about
40:28our research and our particularly
40:32our particular way of conducting
40:35research with Native Americans.
40:37Chris Cutter and I have been working
40:40together for more than a decade.
40:42And we're an example of a flourishing,
40:45diverse ethnoracial team.
40:48We value diversity,
40:49and we believe that it makes us better.
40:54We are committed to addressing issues
40:57in Native American mental health.
40:59In addition, we are highly involved in
41:02mentoring underrepresented students,
41:03from undergraduates to post resident fellows.
41:07Finally. We're committed to
41:09teaching and offer a course on
41:11Native American mental health here
41:13at Yale and at Ani Nakota College,
41:17one of 32 fully accredited tribal
41:20colleges in the United States.
41:23We teach to increase the pipeline
41:25of Native students going into
41:27clinical psychology and medicine.
41:33Native Americans have been treated
41:35poorly by university based researchers.
41:38Part of our mission is to build trust and
41:40to develop mutually beneficial partnerships.
41:44We have forged partnerships with
41:46urban and reservation communities
41:48by avoiding the study of pathology.
41:52We are interested in documenting
41:54strengths instead of weaknesses as
41:56an antidote to the over focus on
41:59native weaknesses in the literature.
42:02We've consciously chosen to study therapists
42:05rather than patients for several reasons.
42:08Therapists are arguably less
42:11vulnerable than patients.
42:13Provider studies are easier to
42:15implement and cause less strain on
42:17clinical systems and patient studies.
42:23We study treatment as it naturally occurs.
42:25In native clinical settings.
42:28We have avoided implementing
42:31manualized treatments.
42:32Because most have not been
42:34tested with native people,
42:35we also need to spend time
42:38learning what native clinicians
42:40are doing and doing well before
42:42we can start making suggestions.
42:46Initially, we focused on urban clinics
42:50rather than reservation clinics because
42:52they tend to have fewer moving parts.
42:58We deliberately chose to study
43:01process rather than outcome in
43:03our psychotherapy research.
43:05First, very little is known about
43:08psychotherapy with Native American patients,
43:10and we were curious to know more about what
43:13happens behind the consulting room door.
43:15Second, it made sense to focus on
43:19what is happening clinically before
43:22we look at what are the results.
43:27We partner with psychotherapy
43:29research leaders in this line
43:30of research for several reasons.
43:33First, we're happy to have
43:35the technical expertise.
43:37Second, we want to get them excited
43:40about the possibility of including
43:42native people in their studies.
43:44Third, we want to show that
43:47doing so is feasible. Finally,
43:49we are very inclusive with authorship.
43:53Including partners at clinical
43:55sites and students as coauthors,
44:02we are working on multiple levels,
44:04from measuring individual resilience
44:07in youth development professionals
44:10up to the study of therapeutic
44:12dyads and then up to communitywide
44:14interventions such as suicide prevention.
44:18Each level is important and I
44:20would like to share a bit about.
44:22Our work with our partners.
44:24I hope this work inspires you to reach
44:27out to us and to get involved in the work.
44:31We have conducted needs assessment
44:33projects with tribal communities
44:36in Montana and Oklahoma,
44:38focusing on providing A multipronged
44:41approach to suicide pre and postvention.
44:46In addition,
44:47we have fostered a close relationship
44:49with the Native Services Division
44:51of the Boys and Girls Club,
44:53which is the largest Native youth serving
44:56organization in the United States.
44:58We host an annual training conference
45:01for Native Services staff here
45:03at Yale and conduct research on
45:06constructs such as resilience and
45:08trauma Informed practice with their
45:11youth development professionals.
45:13Finally,
45:14we are conducting psychotherapy
45:15process and outcome studies.
45:17One example is our work with
45:20colleagues at Penn State and the
45:23Center for Collegiate Mental Health
45:25to examine process and outcome data
45:27in a large multi site sample of
45:30native college counseling centers.
45:37I would like to say more about
45:39our psychotherapy research work,
45:41partly to generate interest in collaboration.
45:44Psychotherapy is a helping relationship
45:47that has demonstrated efficacy for
45:50members of the population at large.
45:52The average treated patient
45:55experiences a significant,
45:57measurable reduction in psychological
45:59symptoms and an increase in functioning.
46:03However, very little is known about
46:05the processes and outcomes of Native
46:08American patients in psychotherapy
46:10because there's an extreme
46:12paucity of research in this area.
46:19When Native people as a group
46:22have so many pressing needs,
46:24why study an individual
46:27intervention such as psychotherapy?
46:29The answer is that Native Americans
46:31receive a lot of Western European
46:33style counseling intervention.
46:38The Indian Health Service alone
46:40provides over 200,000 behavioral health
46:43contacts for Native Americans per year.
46:47There's been there's been much
46:49theorizing in the absence of data
46:52about the utility or futility of
46:55psychotherapy for Native people.
46:57Both directive and nondirective
46:59counseling practices have been
47:02recommended for Native clients,
47:04but few studies have been conducted
47:07to determine the appropriateness
47:09of either approach.
47:11There has been some investigation
47:13counseling process, mainly by our group,
47:16including expectations about counseling,
47:19therapist technical activity,
47:22and the working alliance.
47:24An early study by Sue and colleagues,
47:281978 revealed increased risk for
47:31dropout for Native American clients,
47:34a group that also received
47:36numerically but not statistically,
47:38significantly fewer counseling
47:40sessions compared to white clients.
47:44Very few studies have examined
47:47counseling efficacy or effectiveness
47:49for Native American clients.
47:51One small study signaled a better response
47:54to motivational enhancement therapy
47:56compared to cognitive behavioral therapy,
47:59or 12 step facilitation for Native American
48:03participants in addiction treatment.
48:06Lambert and colleagues conducted an
48:09effectiveness study examining college
48:11counseling clients by racial group,
48:13including 73 Native American clients.
48:17No statistically significant
48:19differences were detected.
48:21On either single session, attendance,
48:24which could be possible dropouts or outcome,
48:28is measured by the outcome questionnaire.
48:31While this study has much to recommend it,
48:34it does have some limitations.
48:36First,
48:37the data were drawn from a single
48:40college counseling center located
48:42within a unique university BYU,
48:46which presents limits to generalizability.
48:49Second.
48:49Cultural commitment and Native
48:51clients was not measured.
48:56Better understand psychotherapy
48:57with Native patients.
48:59We inaugurated a line of psychotherapy
49:02process research and have begun
49:04to publish work in this area and
49:07I will talk briefly just about
49:10the first study in this series.
49:14We were very curious to know which techniques
49:17are used with Native American patients.
49:20So we asked therapists working in
49:23native clinics to report technique use
49:26immediately after service delivery.
49:29We collected data from six therapists
49:32across 3 urban Native clinical sites.
49:35The therapists were licensed professionals
49:38with ample clinical experience.
49:40We collected 93 unique consecutively
49:44rated sessions in total.
49:51More sessions with female patients
49:54were rated, the mean age was 40 years,
49:58and all patients were Native American.
50:01They had typical outpatient diagnosis
50:04like depression and anxiety,
50:07and generally moderate problems
50:14following a session.
50:16Therapists describe their
50:17technique use with the multi
50:20and empirically derived list
50:22of therapeutic interventions
50:29and measures techniques from
50:318 theoretical orientations.
50:33Participants also filled out
50:35a demographics questionnaire.
50:41And so therapists reported using a variety
50:44of techniques, mostly common factors.
50:46So the mean here ranges from 1:00 to 5:00,
50:49and common factors were rated at 4.
50:55Techniques from the seven schools
50:57of psychotherapy were employed at
50:59rates lower than the standardization
51:01sample means and significantly lower.
51:04Person, centered and interpersonal
51:07were the most common technique types.
51:10Implying a warm,
51:12supportive and non directive rather than a
51:15challenging and directive clinical stance.
51:19An empirical finding that bears directly
51:23on the directive non directive debate.
51:28This
51:33work has brought us into contact with
51:35researchers across the United States.
51:37Here is a partial list of our collaborators.
51:47We could not do this work
51:49without significant support.
51:51We would like to thank Doctor
51:53Charles Carl for his enthusiasm for
51:55helping Native people and for his
51:58support of this work in particular.
52:00We also honor the leadership of
52:02Doctor Linda Mays and thank her
52:04for her openness as well as her
52:06expert and generous mentoring.
52:08Finally, we owe a debt of gratitude
52:11to our students who bring so much
52:14excitement and energy to this work.
52:17And here's our contact information.
52:19Please feel free to reach out.
52:24I
52:29think we could probably open it
52:31up to questions and comments.