American Indian vocational rehabilitation services: a unique approach.
* American Indians had a disproportionately high incidence of disability.
* American Indians had a disproportionately high rate of unemployment.
* The percentage of American Indians employed in low scale jobs was disproportionately high.
* Among American Indians who were employed, a disproportionately high incidence of disability occurred on the job.
These results were corroborated by data reviewed by Kuehn and Imm-Thomas (1993). Their investigation was a response to an observed correlation between the rate of infants born with low birth weights in a population and the percentage of individuals who subsequently exhibited developmental disabilities within that population. Though the percentage of American Indian infants with low birth weights was comparable to that in the general population, there were significantly higher mortality rates for both neonates and adults among American Indians. The combined effects of these statistics was interpreted as an indication of a greater proportion of developmental disabilities among American Indians.
Other examples of disabling conditions that have been reported as occurring with unusual frequency among American Indians included alcoholism (Kivlahan, Walker, Donovan, & Mischke, 1985; May, 1986; 1988), mental health problems (May, 1987; 1988), communication disorders (Thielke & Shriberg, 1990), drug and substance abuse (May, 1986), depression (May, 1987), fetal alcohol syndrome (McShane, 1988), and the early display of symptoms associated with aging (Martin, White, Saravanabhavan, & Carlise, 1993). Although the incidence of such disabling conditions has been reported as higher among American Indians as a group than among the general population, there can be significant variability in rates of occurrence between tribes (Justice, 1987) and among members of the same tribe. Variability in rates of incidence for disabilities among American Indians has been linked to age as well as social and economic factors (Logue, 1990).
Some critics (Morgan, Guy, Lee, & Cellini, 1986; Morgan & O'Connell, 1985; Toubbeh, 1987; 1989), observing the prevalence of severe disability among American Indians, have argued that American Indians should receive priority as clients for effective rehabilitation programs. However, traditionally organized and delivered rehabilitation programs have been largely unsuccessful with American Indians. Because of the incongruity between the assumptions on which these programs are based and the assumptions on which the beliefs of American Indians are founded, critics of traditionally organized programs have even questioned whether such programs constitute a barrier rather than a pathway to rehabilitation.
Recounting case studies of American Indians, Joe and Malach (1992) highlighted the distinctive linguistic patterns and cultural values that can prevent the simple extrapolation of intervention models of rehabilitation. On the basis of distinctive features of American Indians, they emphasized the need for family centered assessment and intervention. They advised that service models be implemented by professionals who are sensitive to the social, psychological, philosophical, and spiritual values of American Indians. After reviewing case studies of several American Indians with disabilities, O'Connor (1993) noted that, "... to better understand the meaning of services to Indians, it is important to look not only at programs, but also at the cultural background of the people using the services ..." (p. 315). Locust (1988) recommended that practitioners develop a rapport with their clients, attempting to view their clients' disabilities from a perspective within the culture of American Indians. The National Indian Council on Aging (1981) stressed the need for culturally sensitive services as well as the inclusion of American Indians themselves in both planning and implementation. Recognition of clients' legal right to participate in the planning of services that affect them can be extended beyond American Indians to all individuals with disabilities, irrespective of their ethnic origin or the severity of their disabilities (Gerry & Mirsky, 1992).
Levy (1987) stressed that beliefs between tribes can be sufficiently distinct to influence responses to medical services. As an example, distinct assumptions about the cause of epileptic seizures by Pueblo and Navajo Indians may have been responsible for the greater number of social and emotional problems exhibited by Navajo Indians with epilepsy. Other investigators have examined the possibility that shared group values of American Indians have influenced their perceptions of visual impairment (Lowrey, 1987) and emotional disturbances (Scruggs & Mastropieri, 1985; Thomason 1991; Trimble & Fleming, 1989).
A survey of vocational rehabilitation counselors who worked with American Indians (Martin, Frank, Minkler, & Johnson, 1988) indicated that the counselors viewed sensitivity to their clients' cultures and communities as essential components of effective intervention. Although this sensitivity was noted by counselors who worked with clients on the reservation as well as counselors who worked with clients off of the reservation, cultural sensitivity was evaluated as more important by the counselors who worked with clients on the reservation. A culturally adapted network of community support was judged to be critical for all American Indians during the phase of rehabilitation that followed counseling.
Hodge and Edmonds (1988) described vocational rehabilitation projects for American Indians on three reservations. Recipients of services, for whom the average age was the early thirties, were unemployed, living in poverty, and receiving medical care. In addition to lack of adequate finances, inadequate transportation resulting from geographic isolation was identified as a major obstacle to counseling and rehabilitation. Joe (1988) argued that many rehabilitation services were inaccessible to American Indians because of bureaucratic confusion among agency personnel about their responsibilities and because of the geographical remoteness of many American Indians.
There have been several rehabilitation models that have been based on cultural sensitivity and limited geographical accessibility. Family based systems of care (Cottone, Handelsman, & Walters, 1986; Emener, 1991; Joe & Malach, 1992; O'Connell, 1985) involved family and agency collaboration to ensure that services would be available in rural communities when professionals were not accessible. Other models have developed progressive empowerment, with American Indians being trained as paraprofessionals or professionals (Runion & Gregory, 1984; Stuecher, Grossman, Hakala, & Kizlowski, 1985). There were still other models that have been built on collaboration between paraprofessionals or professionals, who may or may not have been tribe members, and who had been trained about the distinctive needs of American Indians receiving rehabilitation (Martin, White, Saravanabhavan, & Carlise, 1993; Yukl, 1986). After reviewing a survey of 17 American Indian vocational rehabilitation projects, Lonetree (1990) called attention to a conclusion formed by proponents of all of these models: effective models require cooperation between state, federal, and tribal agencies.
Models for delivering services to American Indians are somewhat comparable to rehabilitation models for persons representing a broad multicultural background (Christensen, 1989; Dodd, Nelson, Ostwald, & Fischer, 1991; Levine, 1987; Lynch & Hanson, 1992). For example, though the culture, values, attitudes, and language of minority groups can be distinct, sensitive and flexible responses to these factors are conditions for effective rehabilitation. Consequently, vocational rehabilitation counselors who are trained with models for American Indians should be able to adapt those models for persons from other minority groups. Nonetheless, there is still a distinct and critical characteristic that distinguishes service models designed for American Indians. This distinct feature is responsiveness to clients who are usually in geographically inaccessible locations.
Kuehn and Imm-Thomas (1993) identified five critical issues that needed to be examined before service delivery models developed with non-minority populations could be extrapolated to American Indians and other minority groups. These issues comprised availability, access, cost effectiveness, accommodation, and cultural appropriateness. Two of these factors, accommodation -- which refers to the interpersonal attitudes of professionals within service agencies -- and cultural appropriateness, are linked directly to the backgrounds, values, and attitudes of agencies' clients. In the case of American Indians, availability and access are linked inextricably to problems of geographical remoteness. And if one considers pervasive poverty as a factor that intertwines with the backgrounds, values, and attitudes of adults with disabilities, cost effectiveness could have an influence as significant as culture (Traustadottir, Lutfiyya, & Shoultz, 1994).
A Unique Vocational
Rehabilitation Services Project
The American Indian Vocational Rehabilitation Services Project followed a pilot study developed through an agreement with the All Indian Pueblo Council. It involved collaboration between the New Mexico Division of Vocational Rehabilitation and American Indian tribes in New Mexico. Its goal was to provide individual vocational rehabilitation services to American Indians at 19 pueblos and on two Apache reservations. The American Indians at each of the 19 pueblos are members of sovereign, federally recognized tribes. The constituents of these tribes are extremely heterogeneous, exhibiting diverse cultures and speaking diverse languages. In addition to Spanish and English, residents of the various tribes communicate in seven indigenous American Indian languages (Apache, Keresan, Tewa, Tiwa, Towa, Navajo, and Zunian).
Originally funded in 1987, the project followed an exhaustive investigation of the rehabilitation needs of American Indians of Pueblo descent or other American Indians residing within the Pueblo communities. The subjects of this investigation were 117 residents who were interested in being referred for rehabilitative services. As an example of the linguistic diversity of this group, 34 percent of the respondents requested that the interviewers use their native language during the interview; and 74 percent of the interviewed persons indicated that they actively used their native language.
Nearly three-fourths of the interviewed persons were in financial crises and the majority did not have medical insurance. Most of the respondents were not employed; and those who had been employed recently reported mean salaries of $8,000 a year. More than half of the respondents were unemployed and not actively seeking jobs. Among persons actively searching for jobs, one-third had been searching for over a year. The disabilities they reported during the interviews included physical problems, nervous system disorders, mental disorders, emotional problems, and alcoholism. Some of the reported problems were the result of accidents and others resulted from developmental disabilities.
Based on the interviews, the project personnel identified barriers that hindered the implementation of rehabilitative services to American Indians. The obstacles included language, geographic isolation, transportation, inadequate rehabilitative services, and lack of available jobs.
Following the survey, a unique project was implemented. The project was intended to provide concerted services in vocational rehabilitation that would be delivered in an alternative fashion. This specific model was linked to the survey's results as well as a conviction that American Indians had been underserved in the past. Adaptations to traditional models of service delivery were designated as a means of reducing or eliminating the barriers identified by the respondents to the preproject survey.
Culture was not identified as a barrier so much as an inevitable aspect of the diversity that characterized the populations of New Mexico. For example, there are 22 federally recognized Indian tribes within the state, including 19 Pueblo Indian tribes, 2 Apache tribes, and a large segment of the Navajo Nation. Rehabilitation agency personnel made the distinction that culture was not a barrier, hoping to characterize a positive philosophy of multiculturalism on the part of the agency. Clearly, agency personnel understood that a monolithic approach to providing services to multicultural populations would represent a genuine threat to any service system model.
To ensure that cultural diversity strengthened rather than challenged the project, rehabilitation technicians were employed. The rehabilitation technicians were paraprofessionals drawn from the Indian tribes. The technicians spoke the languages used in the pueblos and were committed to providing services in clients' own communities. This model was viewed as an avenue to culturally sensitive services that would circumvent problems associated with geographical isolation, transportation, communication, and the accessibility of services. Since an explicit goal of the project was to prepare individuals for employment opportunities in their own communities, the problems posed by inadequate jobs could be reduced as well. Additionally, members of the tribes would participate in the design and delivery of services through the feedback they had provided on the pre-project survey They would also participate through opportunities to serve as rehabilitation technicians and through opportunities for ongoing dialogue with the rehabilitation technicians.
An additional problem identified by agency personnel was a history of reluctance within many American Indian families to refer persons with disabilities for services. The ongoing presence of paraprofessionals who themselves were residents of the pueblos was intended to raise the likelihood that referrals would be made.
The training and service of American Indian paraprofessionals was intended to have an impact on the clients with whom they would interact. However, another explicit goal of this project was that the rehabilitation technicians would in turn expand the cultural awareness of agency personnel. The project therefore became a two way conduit, with opportunities for agency personnel as well as clients to benefit.
Training of the Technicians
Nine persons served as rehabilitation technicians in this project, and each was guided by a vocational rehabilitation counselor. They met with counselors individually and in groups to discuss the clients assigned to them. Additionally, the rehabilitation technicians attended monthly meetings for inservice training. These activities were supervised by a project coordinator -- an American Indian who had been designated from within the project plan area.
The responsibilities of the rehabilitation technicians were to provide culturally sensitive services in: (1) client referral, (2) vocational goal setting, (3) implementation of Individualized Written Rehabilitation Plans (IWRP's), and (4) job placement. Support training for the technicians focused on topics that were prioritized as needs by project staff at other American Indian vocational rehabilitation service projects as well (Lonetree, 1990). Some of the topics included in this training were:
* vocational evaluation * sheltered employment * rehabilitation terminology * medical terminology * establishing resource contacts * job analysis * job placement * foundations of vocational rehabilitation * medical aspects of disabilities * vocational rehabilitation legislation * development of Individualized Written Rehabilitation Plans * confidentiality
The writing of reports was another key topic for inservice training identified by the project coordinators. But this topic was scheduled for later implementation.
Characteristic of the training as well as the overall project are listed in Table 1.
Table 1 Characteristics of the Model Used in the American Indian Vocational Rehabilitation Services Project
1. the project required collaboration between a vocational rehabilitation agency and American Indian tribes. 2. American Indians were empowered to make decisions about the project. 3. Services were provided in native languages. 4. Services were provided in communities. 5. The project director was an American Indian. 6. Paraprofessionals were drawn from the American Indian communities. 7. Paraprofessionals received systematic training. 8. Paraprofessionals received sustained technical support. 9. Rehabilitation was linked to community employment. 10. The project's American Indian personnel had opportunities to influence the attitudes and values of other agency personnel. 11. the continued presence of paraprofessionals encouraged the perception that services were sustained and available despite changes in governance personnel within the Indian communities. 12. The presence of American Indian paraprofessionals in their own community encouraged referrals from families who might otherwise have been reluctant to make referrals.
Impact of the Project
As an indication of this project's impact, one can examine data from American Indians applying for vocational rehabilitation services in New Mexico. Table 2 identifies the 415 American Indians who applied for services during a 13-month period ending in January 1994 (New Mexico Division of Vocational Rehabilitation, 1994). The applicants are characterized by disabling conditions.
Table 2 Total Number of American Indians Who Applied for Vocational Rehabilitation Services in New Mexico During a 13-Month Period(1)
Number of Type of Impairment Persons Blindness and Visual Impairments 9 Deafness and Hearing Impairments 28 Limb Impairments 102 Loss of Extremities 7 Psychological and Mental Problems (including alcoholism and drug addiction) 212 Miscellaneous Disorders 57 Total 415
(1) Beginning of January 1993 through the end of January 1994.
Table 3 indicates the rehabilitation status of the 415 American Indian applicants at the end of the 13-month period. The categories in Table 3 represent a rough chronology of the rehabilitation process. That process can end in cases being closed successfully by the agency as a result of services, training, and job placement. The table can be viewed as a snapshot of an ongoing process. Because rehabilitation is a dynamic process, the applicants were in varying stages of review and rehabilitation when these data were assembled. For example, at the end of the period, 41 referrals had been initiated that had still not resulted in formal applications, 31 cases were being reviewed, 8 cases were receiving extended evaluations, and 75 applications had been closed because applicants did not qualify for services. An examination of one of the final entries in this table -- the number of applicants who were successfully employed at the end of the period -- indicates that 39 of the 415 total applicants were employed successfully. These figures are limited to progress made by clients during a 13-month period, and additional cases of successful employment certainly emerged during subsequent periods.
Table 3 Rehabilitation Status of American Indians Who Applied for Vocational Rehabilitation Services in New Mexico During a 13-Month Period(1)
Number of Rehabilitation Status Persons In Process of Being Referred to VR Agency 41 Applying for VR Services 31 Receiving Extended Evaluation 8 Application or Referral Closed Prior to VR Services 75 Development of IWRP 56 Unsuccessfully Closed Cases After IWRP 15 Receiving Counseling 26 Receiving Training 54 Ready for Employment 12 Supported Employment 18 Services Interrupted 8 Unsuccessfully Closed Cases After VR Services had Been Initiated 32 Successful Employment after VR Services had been initiated 39 Total Applicants 415
Table 4 contains information about those American Indians who applied for vocational rehabilitation services through the American Indian Vocational Rehabilitation Services Project during the 13-month period ending in January 1994. As such, the persons described in Table 4 are a subset of those in Table 3. The table indicates that all 39 clients who were employed at the end of the period had been associated with the American Indian Vocational Rehabilitation Services Project. Equally impressive, 32 of these 39 successful clients had been involved with the American Indian paraprofessional teams.
Table 4 Status of Persons Who Applied for Services Through the American Indian Vocational Rehabilitation Services Project During a 13-Month Period(1)
Number of Rehabilitation Status Persons In Process of Being Referred to VR Agency 3 Applying for VR Services 15 Receiving Extended Evaluation 0 Application or Referral Closed Prior to VR Services 31 Development of IWRP 24 Unsuccessfully Closed Cases After IWRP 0 Receiving Counseling 3 Receiving Training 14 Ready for Employment 0 Supported Employment 1 Services Interrupted 1 Unsuccessfully Closed Cases After VR Services Had Been Initiated 0 Successful Employment After VR Services Had Been Initiated (2)39 Total Applicants 131
(1) The 131 applicants described in this table were a subset of the 415 applicants identified in Table 3. (2) All of the 39 successfully closed cases during the 13-month period, identified in Table 3, were associated with the American Indian Vocational Rehabilitation Services Project; 32 of the successful cases were associated with the American Indian paraprofessional teams.
The preceding data indicate clearly the project's positive impact. The 39 persons who had successful jobs worked an average of 29 hours per week. The mean hourly wage had been $4.52 an hour; and the mean weekly wage had been $130.16.
A review of the literature concerning rehabilitation of American Indians indicated that the extension of vocational rehabilitation services to American Indians with disabilities is complicated by cultural, geographical, social, linguistic, and financial problems. A unique project was described that was built on collaboration between the New Mexico Division of Vocational Rehabilitation and American Indian tribes in New Mexico. The project employed American Indians who communicated to persons in their native languages while providing services in the communities of those American Indians. The American Indians who received rehabilitation services were empowered to make decisions about the project and the project's American Indian personnel had opportunities to influence the attitudes and values of other agency personnel. Data were reviewed indicating that all American Indian rehabilitation clients in the state who were successfully employed at the end of the review period were associated with this project.
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The authors gratefully acknowledge the contributions of all of the personnel associated with the American Indian Vocational Rehabilitation Project. Without their support and commitment, this project could never have been developed.
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|Date:||Mar 22, 1996|
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