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The Indigenous Population

There are 3 million indigenous people in the United States, belonging to more than five hundred federally recognized nations. It’s important to remember that today Indigenous peoples mostly live in urban centers, rather than reservations, and are a heterogeneous group, representing hundreds of nations each with their own cultural practices and history.

Indigenous peoples may call themselves “American Indian,” Native American,” “First Nations” and “Indigenous.” Alaska Natives and Native Hawaiians are included as well. To indigenous peoples, the United States and Canada is collectively called “Turtle Island.” People who are “part indigenous” usually don’t identify that way. In fact, it is perceived as marginalizing and insensitive to introduce an indigenous person as “half Navajo” when the person self-identifies simply as Navajo.

Significant History – Events which Influenced the Community and Contextualize Assessment and Treatment

Having an accurate history of the colonization of the Americas is necessary in understanding the unique place in history of Indigenous peoples. Genocidal practices through massacres, forced relocations, and the rupture of Indigenous family and cultures was pervasive in the settlement of the United States. Native peoples have struggled to maintain identity as they were imprisoned for practicing their ceremonies and cultural events. For example, in Canada, the Potlatch, a time of sharing food and goods, was outlawed. Later, children were taken away from their families and sent to schools where they were punished for speaking their own language.

There are several significant periods in US History that exemplify the genocidal policies of the United States upon the American Indian. Indigenous Peoples have personal, and family histories of forced relocation. Examples include the Navajo Long Walk of 1864, a 300 mile forced march of 8,000 Navajos to a military concentration camp in southern New Mexico; and the Cherokee “Trail of Tears” in 1838, a forced march of Cherokee women and children from their homelands in Georgia and Alabama to Oklahoma. Subsequently, beginning with The General Allotment Act of 1887 and continuing through the 1960s, forced assimilation and land appropriations led to the termination of more than 100 Indigenous nations and the widespread seizure of Indigenous lands. The United States eventually created federally recognized reservations, in Canada these were called Reserves, many not on the indigenous sacred homelands.

This history of trauma has resulted in intergenerational trauma. Children being forcibly removed from their homes to be raised in boarding schools still impact how parents raise their children. Indigenous peoples experience higher rates of substance use and related disorders, PTSD, and suicide, all of which are directly associated with this intergenerational trauma on Indigenous peoples. As one staggering example, Indigenous peoples are 526% more likely to die from alcohol use than are non-indigenous people.

In addition to mental health, other health disparities also continue to be an issue. Death rates from preventable diseases such as diabetes and infant mortality rates are significantly higher. Willingness to access care is also an issue. Many Indigenous people feel stereotyped, ignored, and disrespected by non-Indigenous providers. Many programs serving Indigenous people are often not culturally relevant or sensitive to the significant trauma within Indigenous communities.

Best Practices for Working with Indigenous Patients

Knowing the history of Indigenous peoples is critical in implementing best practices. Here are a few best practices to keep in mind when working with Indigenous people:

1. Given the significant trauma, PTSD should be high on your differential diagnosis, which is often missed or misdiagnosed as depression or borderline personality.
2. Acknowledge the “intergeneration trauma” including the loss of sacred lands, forced assimilation, and family ruptures. Emphasize and validate the strength of the survivors.
3. As a psychiatrist, remember the importance of a receptive environment that is inviting and welcoming. Engage patients with support and facilitate completion of forms in a receptive environment. If culturally appropriate, you may want to consider decorating your office with art, pottery, baskets, or rugs from the local area. Intake forms may also need to be translated to the language of the indigenous people in the area. Staff should not impose a form if the person is not ready for it. Be mindful that there has been mistrust of clinics run by the federal government, which have a history of ulterior motives.
4. The Evaluation should be thorough to avoid stereotypes and misdiagnosis. Allow the patient to tell their story, and encourage them to share their cultural identity. Stereotypes psychiatrists should avoid include assuming that Indigenous people do or don’t practice their native religion or that those who don’t speak their native language are less Indigenous. As an example of the complex religion of indigenous peoples, on the Navajo reservation there have been churches established in the heart of the reservation where the Navajo people have been converted to that religion, yet they speak only Navajo and wear traditional clothing. Another religion stereotype is that all Indigenous people practice the same religion. While spirituality is practiced by many Indigenous peoples, each native group has their own ceremonies and practices. Know that some will be more willing to discuss their religious practices with a nonindigenous person than others.
5. The cultural formulation interview is very helpful in addressing these issues and approaching the patients from where they are coming from. Allow the patient to tell their story, Indigenous history is often passed down orally rather than in written format.
6. A transition from evaluation to therapy and treatment should be a soft hand off to the therapist and psychiatrist. A soft handoff is an integrative practice where the psychiatrist and primary care provider work closely together. Therapeutic process should be tailored to the individual person and not the clinic or federal facility. While there is not much research on the ethnopsychopharmacology of indigenous peoples, in my experience starting slowly and in lower doses works best to avoid negative effects from polypharmacy.
7. The discharge process should be thoughtful with ongoing accessibility for care made explicit.

Future Needs

Improving the care indigenous peoples receive can help so more Indigenous people will seek out the health care they need and improve outcomes.

The future looks optimistic as more Indigenous peoples are entering the medical field and several Medical Schools creating centers for American Indian and Minority health. Hopefully, these steps forward will increases awareness of American Indian health care issues, and lead to more research that serves the health interests of Indigenous communities.