Cultural Competence Standards in Managed Care Mental Health Services For Native American Populations | Preamble

In the United States, the terms Native American, Indian, and American Indian are commonly used and have been considered interchangeable when referring to aboriginal people of the continental United States, i.e., American Indians, Eskimos, and Aleuts. In this document, Native American also includes the natives of Hawaii.

The opportunity to highlight literature and articulate current thinking about what constitutes culturally competent mental health diagnosis and treatment of Native Americans is a welcome one for the Native American Panel. Although very little has been written that directly addresses managed care for Native American populations, there exists a foundation of writing and thinking that is very relevant to this issue. The Panel is very cognizant that this body knowledge is emerging and far from complete.

The Panel further acknowledges the rich diversity that exists among the hundreds of tribes and villages, and which exists within urban Native communities. Census data report that there are approximately 1.9 million American Indian, Eskimo, and Aleut people in the United States (U.S. Bureau of the Census, 1990). About half live on federal Indian reservations in 33 states, mostly located in the western states. The other half of the population live in urban areas, although some reside in small off-reservation communities. The Indian population is young, approximately half are 18 years of e or younger (Nelson, McCoy, Stetter, & Vanderwagen, 1992). [Add demographic information about Native Hawaiians here.]

The importance of mental health services to Native people must be understood in view of historical, geographical, educational, and tribal contexts. Of great importance is understanding the impact of colonization on Native people and the corresponding issues of mental health (Duran & Duran, 1995). Although some early contacts between Natives and Europeans were positive, most were not. At contact there were several million Native peoples. It can be rightfully stated that from the point of contact with Europeans, holocaust conditions led to the annihilation of some, and near destruction for other tribes across the Americas and the Hawaiian Islands. Diseases foreign to Native people wiped out over half of the Native population. The impact of these diseases is still being felt in Native country. Disease killed many leaders and elders thus cutting off tribal leadership, as well as the sources for knowledge and tradition. Furthermore, the power of the medicine people was undermined, since there were no cures for disease over which they had knowledge. The memories remain for Native people about what Whites did through deliberately providing Natives with infected blankets as "gifts"-an early form of germ warfare (Vogel, 1972).

Forced relocation was another factor which caused many deaths as well as numerous other problems--many mental health related. Dealing with the reality of being conquered, the shame, the forced dependency upon the U.S. government, and the stripping of traditional roles for the men, women, and children has impacted tribes for centuries. The pain of the "Trail of Tears" or long walks made by tribes remains in the hearts and minds of Native people today. Other impacts of forced relocation include: dealing with broken treaties, restrictions to reservations (historically, an Indian had to have a permit in order to leave the reservation), the poverty conditions, and the consequences of not relocating-oftentimes meant destruction and death (O'Sullivan & Handal, 1988; Vogel, 1972). Alcohol was another devastation (Berkhofer, 1978) and is considered to be the number one problem in Native country today.

Forced education through boarding schools caused considerable damage to the structure and function of tribal societies as well as to the mental health of Natives. Historically, Native children were taken from their tribal homes to attend boarding schools sometimes hundreds or thousands of miles away. They were forbidden to speak their tribal language, given new names, usually a uniform, their hair was shorn, and they were taught the ways of White society. The early charters for Native education were the same: to remove the child from the influence of his or her "savage" parents. Today, approximately 25% of Native children attend boarding schools. The horrible effects of boarding schools on tribes extend to the undermining of tribal ways of parenting, traditional child-rearing, use of language (many a story about a child finally returning home and being unable to speak to his or her parents any longer), the negative messages about Natives, and the forced assimilation of White ways have had devastating consequences. Today, there are counseling groups specifically designed to address the effects of boarding school education experiences.

In terms of health care, the U.S. government has had the responsibility through the obligations of many treaties. Typically, these obligations were carried out through the Public Health Service via Indian Health Service (IHS) and Bureau of Native Affairs (BIA). The Public Health Service in 1955 assumed primary responsibility for providing health care to Natives and currently the IHS services approximately 60% of the Indian population (Johnson, 1995). IHS services include clinical care as well as environmental health, facility maintenance, and critical public health functions. The hope was, that once fully developed and comparable to the nation's health care systems, Congress could then relinquish its responsibilities to Natives. This goal was part of the termination policy formulated by Congress during the Truman administration. Under Nixon's self-determination policy, tribes were encouraged to take over the governing of their health care programs (Flack, 1995). Under Public Law 93-638, 300 tribes across the nation now compact or contract with the federal government to provide part or all of the health care for their tribal members. Furthermore, there exists 41 urban Indian health clinics which although enormously underfunded, attempt to serve the most disadvantaged Indians and those from distant tribes who may not be eligible for IHS contract services.

Presently, there are numerous agencies/departments involved in various degrees in the provision of mental health services to Native people. At the broad systems level, there is a lack of clarity regarding the roles of IHS, the BIA, the state, counties, cities, and tribes in mental health care. There are relatively few working agreements between these service delivery systems (WICHE, 1993).

The panel has many concerns about managed care as a model of health care delivery for Native Americans. Of particular concern is the use of a prepaid or capitated approach to service payment. Issues effecting Native people are complex and linked to historical events and current experiences that are perpetuated by current events that, on the surface, do not seem related. However, because of the historic trauma suppressed by many Native Americans, subtle messages which communicate a lack of belonging to contemporary American society, and the continuing assault on Indian sovereignty serve to perpetuate mental health problems. Managed care organizations which do not address these complex issues in a careful and thoughtful manner with Native American consumers, sovereign tribal nations, native organizations, and relevant federal agencies will only add to the oppression experienced by Native Americans for decades.

Having stated these concerns, the Native American Panel offers the following standards and implementation guidelines toward the goal of developing culturally competent managed care organizations that would serve Native Americans in ever increasingly effective and respectful ways. In reviewing the system and clinical guidelines, it was agreed that guidelines for Provider Competencies would be the same regardless of the setting (urban, suburban, rural, reservation), but all other guidelines were reviewed with the rural-reservation managed care settings in mind separately from the review with urban-suburban settings in mind. In many cases, the same guideline applies to both groups. When this is the case, both urban/suburban and rural/reservation groups are identified in the subtitle. It is highly likely that the urban-suburban managed care settings would be non-Native and most likely, non-minority specific. In considering the rural/reservation situation, we found it useful to use the Navajo Nation as a reference point. The Navajo Nation has sovereign nation status over its membership residing on or near the reservation, a very large geographic area located in three states (Arizona, New Mexico and Utah). This illustrates the complexity in developing culturally competent health care for one tribal nation.



The Native American Panel would like to acknowledge the National Latino Behavioral Health Workgroup for their excellent work to develop a framework for stating the principles and guidelines. Having the framework as a foundation greatly facilitated the work of the Native American Panel.