Native American culture and psychiatry
Native American people are typically diagnosed with higher rates of “mental illness” than white North Americans. Similar findings occur in Australia and New Zealand. Historically Native American people were viewed by psychiatry as primitive, narcissistic, and withdrawn, among a host of pejorative attributes. Early psychoanalytic research leaned heavily on Native Americans to demonstrate primitive defense mechanisms and the inherent deficiencies of being on the margin of civilization. Gustafson (1976), for example, wrote that Lakota people were to primitive to engage in psychoanalysis, being unable to consider that lying on a couch and talking to someone who doesn’t answer might seem ridiculous to members of another culture who had not learned to value this procedure.
Higher rates of depression, anxiety, and other illnesses have been documented among North America’s aboriginal people. However, when Mansur and colleagues (2007), for example, looked at the rates of anxiety and depression on reservations in Montana, they were actually lower than the white communities around the reservation. They explained their findings by the much greater social support and family connectedness existing on reservations than in white communities. Therese O’Nell (2000) went to a Flathead community in Montana, expecting to find high rates of depression. Instead she found a cultural and linguistic mismapping of what Flathead people consider to be a highly desirable state (“to be worthy of pity”) onto what mainstream psychiatry calls “depression.” Flatheads who were worthy of pity did not appear to be depressed in the DSM sense of the word, at least to her.
Native Americans are also accused of having more alcoholism than white Americans, though research shows actual lower levels of alcoholism and higher levels of binge drinking on reserves than their neighboring white communities. Nevertheless, the stereotype of the drunken Indian has become a cultural icon, for both aboriginal and non-aboriginal people. O’Nell describes drinking and being drunk as being a potential source of Indian pride and ethnic identification among Flathead people in Montana. Thacker (2006) describes the historical origins of binge drinking in laws that put an Indian in jail for one day for being drunk and for 90 days for being in possession of alcohol. The law conspired to produce a motto of “when you drink, drink it all”. Dry reserves and still existent laws limit opportunities to learn and practice more responsible, low level consumption of alcohol. Psychiatry has attempted to paint a picture of aboriginal people being genetically susceptible to alcoholism, when poverty actually serves as a sufficient explanation. Social determinants of emotional pain and suffering are readily appreciated on aboriginal reserves (high unemployment, crowded housing, poverty, little social enrichment or recreational opportunities), though psychiatry searches for genetic, deterministic explanations for higher rates of suffering and pain. Given the stewardship of the mental health profession by psychiatrists, resources are directed toward increased access to biomedical care, hospitalizations, 28 day treatment programs, and medications, than to solving the social problems which contribute toward substance abuse on reserves. Certainly, during my four years of working on reserves in rural and remote Saskatchewan, I encountered unlimited funds to send people by themselves to 28 day substance abuse treatment programs and no funds to develop community resources for when they came home. Apparently alcohol policies were managed by competing departments. Health Canada would pay for an unlimited succession of 28 day hospitalizations, but very little in the way of community development and social resources for maintaining a healthy lifestyle.
Historical reports by early explorers and missionaries of North American peoples call forth images of happy, sociable, gregarious people. While we do not want to overly romanticize pre-contact culture, we can say that generosity and hospitality were seen as virtues (see Potlatch cultures). Suicide, except in situations of grave dishonor, was rare. Children were raised in a manner that promoted healthy attachments, as is common in tribal cultures. War, of course, existed, but not on the scale of European battles. Food was relatively plentiful unlike the famines of Europe. Some degree of interpersonal conflict existed, but police are relatively unnecessary in extended kinship systems because relatives keep their relatives in line. Indeed, beliefs about reincarnation and not being able to escape from one’s difficulties through death probably contributed to people working out difficulties in the present, as well as keeping the suicide rate low. Additionally, practices in which the family was responsible for the deeds of its members mitigated against bad deeds lest all in the family suffer. For example, in some communities, if one family member murdered a member of another family, that family had the right to pick a member of the murderer’s family to kill, to maintain balance. In this case, perhaps the threat of retribution was prohibitory. Additionally, the absence of alcoholic beverages over 5 or 6% alcohol probably helped, since current violent deeds are more often than not associated with intoxication. The lack of other substances of abuse and the cultural taboos of using substances outside of ceremony were also contributory to the social fabric remaining intact. The cultural emphasis on healing, balance, and harmony, and the dramatic opportunities for enactment of illness in ceremonies and rituals contributed to keeping the people psychologically healthy. Additionally, the lifestyle of hunter-gathering people was indeed much less stressful than the agricultural lives of peasants in Europe. Some anthropologists have calculated a 16 hour work-week for aboriginal people in North America, with the remainder of their time spent in ceremonial pursuits or social relationships. The social standard of life, including participatory democracy, enlightened childrearing practices, and awareness of the public health importance of hygiene, were much further advanced in the Americas in 1492 than in Europe, with the exception of the empires of Meso-America and South America, in which forced servitude and mass executions on a scale comparable to England of the same time, existed. Life under the Aztec, Incan, or Mayan emperors was not necessarily much better than life in feudal France, England, or Spain. Nevertheless, North Americans enjoyed a reasonably good standard of life, superior in my view to conditions existing in Europe at the same time.
Historical aboriginal views of mind and mental health were quite different from those of contemporary psychiatry (Mehl-Madrona & Pennycook, 2009). These views are being pieced together through interviews with contemporary elders and through written materials collected by ethnologists, physicians (notably Walker and Eastman for the Oglala), missionaries (Father Beuchtel for the Lakota) and explorers. These views as currently reconstructed were more similar to those of the Russian psychologist, Mikhail Bakhtin, and are compatible with much of what is now being called narrative psychology, which, not surprisingly, is the only branch of psychology to have arisen from ethnic and Native studies, women’s studies, and cross-cultural literary disciplines. Aboriginal views held people as fundamentally healthy and whole. Difficulties emerged from learning and living the wrong stories (for the situation at hand). Self was viewed as relational in the sense of multiple selves existing, one for each relationship in which the person found him or herself. No one self was true or primary. Each self had its own voice, which was mingled with the voices of nature, ancestors, spirits, and the like, to produce a veritable symphony of the mind. The community was considered the basic unit of distress when problems emerged and the individuals expressing distress were likened to our now famous metaphor of canaries in the mine. These people were thanked for suffering for the community and bringing into the open the need for the community to heal. Contemporary Dene ceremonies in northern Arizona continue to display this philosophy in which the entire community feels responsible for the sickness of the individual and all contribute to the enactment of a 9 to 14 day ceremony to restore harmony, balance, and health to the individual and simultaneously to the community.
Contemporary North American aboriginal communities retain elements of the above, which is how we are able to piece together their pre-contact views in an archaeology of psychological perception. Nevertheless, the stories of modern culture have infiltrated every aspect of current aboriginal life. Saskatchewan Cree poet Louise Halfe illustrates this in her poetry in which almost every poem has some reference to the dominant white group. Culture has changed. Our working definition of culture consists of all the stories told or having been told in a locale coupled with the results of their performance or enactment. Through contact, colonization, residential schools, education, and commerce, aboriginal people are slowly absorbing the internalizing the stories of the mainstream culture. Pockets of resistance occur as when traditional cultural healers attempt to maintain their practices or scholars piece together a picture of a world view from the past. Nevertheless, contemporary aboriginal culture with regards to mental health is a hodge podge of old views and those of psychiatry (Mehl-Madrona, 2010). When peoples mingle, their stories mingle, thereby co-mingling their cultures, and reducing the possibility of finding a “pure culture” to virtually zero. Waldram (2004) has written about the attempts of psychiatrists and psychiatric anthropologists to fit their definitions of culture onto North American aboriginal people. Mann (2007) tells a sobering story of anthropology defining a South American people as the most primitive on earth, holding the view that they had made no progress from the stone age, when actually these people were contemporary refugees, almost completely eliminated by the Bolivian government and landholders, who were not living their traditional way, but were moving in hiding and in fear of annihilation. Both Mann and Waldram make the point that scholars see what they want to see, that aboriginal people are a means to an end in scholarship, and that people are twisted in every which way to support theories that are probably unsupportable.
Within contemporary North America, indigenous writers are attempting to construct an indigenous theory of mind and mental health (Duran & Duran, 2000; Duran, 2006, Mehl-Madrona, 2003, 2005, 2007; 2008). The effort is to say, if aboriginal people had continued to develop contemporary theories of mind and mental health, what would those be? The challenge to psychiatry is to wonder if some of these theories might be more useful than contemporary psychiatric theory.
Aboriginal theories predictably focus on relationship and community over individuals and pathology. DSM is foreign to aboriginal thought which looks at every individual as unique, being the result of a unique combination of stories, location, family, relationships, and community. The homogeneity which DSM seeks and purports to have found is rejected. Treatment lies along the lines of restoring harmony and balance to relationships and communities and to providing people with better (more practical, functional, appropriate for the situation) stories to live and to be allowed to live through them. Therapies are spirit guided and relationships with non-physical beings are cultivated to aid in the healing process. This acceptance of magic and supernatural beings in healing is viewed as primitive and primary process thinking by mainstream psychiatry, rejected outright. Nevertheless, aboriginal thought has parallels in the social psychiatry of R.D. Laing, Loren Mosher, John Weir Perry, and others, who described superior results for the treatment of schizophrenia and psychosis using social environments instead of psychopharmacology. Additionally, the importance of community has been highlighted by the World Health Organization’s 20 year schizophrenia study, which found better outcomes in third world countries than developed countries, and mostly in relationship to the intact communities and social support found in India, Nigeria, and Colombia. The hearing voices movement is normalizing voices and voice management techniques over diagnosis of psychosis and psychopharmacology, mostly in the U.K., but to a more limited extent in North America. The positive benefits of elders for mental health problems are being described (Mehl-Madrona, bipolar, 2008), though funding is difficult to obtain for studies, since elders are not capable of being standardized or controlled (Mehl-Madrona, 2010) in the manner demanded for interventions in randomized, controlled trials. Indeed, the politics of evidence production works against elders, since valid evidence is obtained from studies in which all parameters are held constant (so the researchers believe) except for one. Obviously this methodology is best suited to study drugs. Consequently drugs have the most evidence to support them, even if the effect sizes are small.
The future of aboriginal world views in psychiatry is uncertain. Psychiatry has largely directed itself to biology as a means of explanation and treatment. Aboriginal world views explain human biology as a result of the enactment of story and the living of social relationships. Psychiatric epigenetics support these views but have not yet caught hold. Psychiatry attempts to explain unusual behavior as the primary result of damaged or disordered brains, while aboriginal thought seeks to explain brains as being formed by social environments and relationships, leading the primary cause of a disordered brain to be relational and social. Psychiatry has a huge pharmaceutical lobby behind it. In support of aboriginal world views is their sustainability. Drugs are far more expensive in developing countries than are human relationships. Certainly this is true on North American reserves and First Nations communities. Perhaps it is also true for mainstream North America – that the billions of dollars being spent on psychotropic medications would be better spent on jobs – for people to have therapeutic social relationships with those who suffer and are in pain, instead of physicians or physician extenders quickly prescribing very expensive medications of questionable value (see University of Ottawa meta-analysis of antidepressants and CATIE studies).
Certainly the mainstream dialogue of the Obama administration (or the Harper government) has focused upon providing services driven by existing philosophies to everyone (access to care) versus questioning the utility of currently offered services. Especially for aboriginal people, relationship based services may be more beneficial and cost-effective than disease-based services. I suspect this is also true for people of all ethnicities. I suspect that the current health care system is unsustainable in the sense that the headlong rush to develop newer, better, and different drugs is enormously costly, not to mention the manufacturing and marketing of these drugs. I suspect that a relationship model for mental health is far more sustainable and affordable in the long run (though not perhaps in the first three months for psychotic and mood disorders). What if the elders are correct, and that giving people intensive attention and care when they are in crisis is more effective than drugging them and seeing them monthly. What if intensive healing experiences (the enactment and psychodrama of ceremony) is more effective than the professionalism of white-coated doctors and nurses? What if keeping people at home in their communities is more effective (cost and benefit) than hospitalizing people and putting them in mental health care homes, away from family and those who know them. What if those who know us are far more beneficial without any training than those who don’t know us regardless of the depth of training? These are questions that contemporary aboriginal elders pose, which psychiatry ignores (the American Psychiatric Association rejected this year proposed symposia on indigenous models of mind and mental health and on psychiatrists working with traditional aboriginal cultural healers). The power balance currently allows such dismissal. Will this always be the case? I suspect that the health care crisis will have to get much worse for government to begin to question the value of the care we deliver instead of asking the question of how to improve access to the care we give. It will require a late-to-develop understanding that the care as we now deliver it, is unaffordable. It cannot be provided for everyone in either Canada or the United States. Currently Canada solves the problem with high taxes, long waits for elective or semi-urgent procedures, and long waits for specialist care. The U.S. solves the problem by denying care to the uninsured and the under-insured. However, the cost of providing care to everyone will be insurmountable. Here is where aboriginal models of mind and mental health might benefit contemporary society – in providing workable means of providing care than are sustainable and cost-effective, even more beneficial to reducing pain and suffering than the models that are currently dominant.