Perceptions of rehabilitation counselors regarding Native American healing practices.

Native American Healing Practices are those which may involve traditional medicine practitioners, such as medicine men and women, herbalists, and shamen, to restore an individual to a healthy state using traditional medicines, such as healing and purification ceremonies, teas, herbs, special foods, and special activities such as therapeutic sings, prayers, chants, dancing, and sand painting (Chee, 1991). It may also be referred to as "folk medicine" or "Indian medicine" (Avery, 1991).

Nationally, Native Americans represent a culturally distinct group who are currently underserved by the rehabilitation counseling profession (O'Connell, 1987). The National Institute of Disability and Rehabilitation Research (NIDRR) concluded that rehabilitation services do not meet the cultural, linguistic, and social needs of Native Americans (Wright, 1988). Many Native American clients receive rehabilitation counseling services from non-Native American counselors. According to Heinrich, Corbine, and Thomas (1990), these counselors can enhance their counseling effectiveness with Native American clients by learning more about their cultures. An understanding of a Native American client's cultural heritage can improve the quality of the relationship between the counselor and client. Rehabilitation counselors have an ethical responsibility to provide appropriate and efficient services for eliminating obstacles to successful rehabilitation for ethnic minorities (Wright, 1988) and lack of cultural understanding about Native Americans may contribute to problems in the counseling process (Clark & Kelly, 1992).

Native American Healing

Many Native Americans have a holistic view of health perceiving the mind, body, spirit, and nature as one harmonic process. Illness or disability may be considered a disruption of this harmony. Consequently, medicine and religion are a major part of their healing process.

Traditionally, a shaman or medicine man/woman acts as physician, psychiatrist, and spiritual leader, using rituals, herbs, and ceremonial dancing to restore a person's harmony with the natural and spirit world (Lange, 1988).

Hodge (1989) reported that Native Americans visit a healer for (a) spiritual growth, (b) "drying out" from heavy drinking, (c) cleansing, (d) observance, (e) prayer, or (f) death in the family.

Although native healing practices may differ among tribes, common features of healing practices include: (a) aspects of the relationship between the client and helper, (b) designated places of healing, (c) rationales/myths to explain the problem, and (d) prescribed tasks or procedures to affect healing (Schact, Tafoya, & Mirabla, 1988).

Many Native Americans consider traditional medicine sacred preferring traditional medicine men to modern medical treatment and will not discuss healing practices with non-Natives (Becker, Wiggins, Peek, Key, & Samet, 1990). Navajo and other Southwestern tribes generally believe that medicine and religion are virtually identical. Restoration of a healthy state may be achieved through ceremonies, prayers, rituals, and use of botanical medicines that are often made into salves, ointments, teas, and purgatives (Avery, 1991). Great care and respect in gathering and preparing plants must be used to invoke healing powers.

Some Native Americans may use strictly modern or strictly traditional medicine, while others may integrate Native and Western treatments. Most traditional healers freely refer an individual to other practitioners or non-Native physicians.

If a client uses traditional healing practices, awareness and acceptance of these practices by the rehabilitation counselor is one method of bridging the gap between cultures (Avery, 1991).

Native Americans in North Carolina

According to the 1990 U.S. Census, there are 80,155 Native Americans in North Carolina (i.e., 1.2% of the state's total population). The North Carolina Commission of Indian Affairs Annual Report (NCCIAAR, 1990-1991) stated that this is the seventh largest Native American population in the nation. The only federally recognized tribe in the state is the Eastern Band of the Cherokee constituting 7.7% of the Native American population in North Carolina. Six tribes receiving state recognition are Coharie, Eastern Band of the Cherokee, Haliwa-Saponi, Lumbee, Meherrin, and Waccamaw-Siouan. The Lumbee tribe is the largest with approximately 35,000-40,000 members. Although the majority of Native Americans in North Carolina live in rural areas, a significant number have moved to urban areas such as Charlotte, Greensboro, and Fayetteville seeking employment opportunities.

Health care needs of these tribes include: (a) reduction of adolescent pregnancy, (b) increased prenatal care, (c) increased funding for alcohol and substance abuse prevention programs, and (d) funding for preventive and available health care services. Financial need assistance for medical services was also supported by Marshall, Johnson, Martin, Saravanabhaven and Bradford (1992).

Of the 53,649 Native Americans in North Carolina 18 years and older, it is estimated that 19,237 have disabilities and 8,047 have work related disabilities (Parrish, 1992). According to Parrish (1992), 2761 Native Americans were involved with the North Carolina Division of Vocational Rehabilitation Services (NCDVRS) between July 1, 1986 and June 30, 1991. Four hundred twenty-three cases were closed and not rehabilitated, and 769 cases resulted in competitive or noncompetitive employment. This represents 1.8% of the state's successful "status 26" closures which exceeds the state's Native American population of 1.2%. The mean age of those rehabilitated was 29.5 years. Of this group, the most prevalent disabling conditions included: (a) mental/emotional disabilities (17.6%), (b) amputation (17.0%), (c) mild mental retardation (10.7%) and (d) alcohol abuse (10.5%).

Some of the services provided included: (a) counseling and guidance, (b) work adjustment, (c) job seeking skills and (d) placement services. The mean weekly earnings of these clients was $15.03 upon application and $170.26 per week at the time of closure. At closure, 20.4% of Native American clients were placed in service occupations, 19.5% in structural work, 15.6% in bench work, and 11.4% in machine trades. Other occupational categories included: (a) clerical/sales (8.6%), (b) processing (6.6%), (c) agriculture/fishing/forestry (5.2%), (d) professional/technical/managerial (3.8%) and (e) miscellaneous (8.8%).

Methodology

Purpose

The purpose of this research was to identify perceptions of rehabilitation counselors employed by the NCDVRS and the North Carolina Division of Services for the Blind (NCDSB) regarding the use/effectiveness of native healing practices among their Native American clients.

No previous research regarding rehabilitation services to this population in North Carolina was identified.

Local tribes, the North Carolina Commission of Indian Affairs, and individuals knowledgeable about native healing practices in North Carolina were contacted. A local shaman was interviewed and provided a cassette recording of a healer speaking about Native American folk medicines.

Sampling Method

The survey and letter requesting counselor participation were sent to the directors of NCDVRS and NCDSB for approval and feedback. A complete list of counselor names and addresses were obtained from the state agencies. Surveys were mailed to 29 counselors employed with NCDSB. Of the 347 counselors employed with NCDVRS, a sample of 99 counselors (28.5%) with general caseloads covering all regions of the state was randomly selected since it was not known how Native Americans were distributed by caseload. The total sample consisted of 128 rehabilitation counselors. All 128 rehabilitation counselors were mailed the Survey on Native American Healing (SONAH).

Instrument Development

The SONAH was developed based on information from the literature, organizations, and individuals knowledgeable about local native healing practices. Counselors were asked about the effectiveness of specific Native American healing practices. They were asked to rate each item on a five-point Likert-type scale (i.e., 1 = Unfamiliar with practice, 2 = Not effective, 3 = Unsure, 4 = Somewhat effective, or 5 = Very effective).

Validation of the survey was conducted by three professors in the Division of Rehabilitation Counseling at The University of North Carolina at Chapel Hill. Reliability of the respondents' ratings was analyzed using Cronbach's coefficient alpha derived from all pairwise combinations within the data set (Hull & Nie, 1981).

Table 1

Demographics of Rehabilitation Counselors N=94

Age                             Frequency            Percentage

24 - 30                            15                   12.9%
31 - 40                            29                   31.0%
41 - 50                            40                   42.7%
51 - 60                            10                   10.9%
Unspecified                         3                    3.2%

Gender

Male                               55                   58.5%
Female                             39                   41.5%

Race

Caucasian                          84                   58.5%
Black                               9                    9.5%
Unknown                             1                    1.2%

Years of Experience

Less than one                       2                    2.1%
1 - 5                              30                   32.0%
6 - 9                               8                    8.6%
11 - 15                            15                   16.0%
16 - 20                            22                   17.1%
21 - 25                            23                   24.4%

Years of Service to
Native Americans                Frequency            Percentage

0                                  54                   57.4%
1 - 5                              18                   19.1%
6 - 10                              5                    5.4%
11 - 15                             5                    5.4%
16 - 20                             5                    5.4%
21 - 26                             7                    7.5%

Familiar with Native
American Healing

Yes                                29                   30.0%
No                                 65                   69.1%

The Cronbach alpha revealed a high reliability coefficient of .90. After a pilot test among twelve graduate students in the Division of Rehabilitation Counseling, revisions of the instrument were made to clarify certain questions.

Data Collection

The survey and a letter explaining the research was mailed to the counselors. A pre-addressed, stamped envelope was included to increase response rates. Surveys were coded for the purpose of follow-up phone calls and postcards for nonrespondents. Data was analyzed using the Statistical Analysis System (SAS) (1987) to provide descriptive statistics and other analyses.

Results

Demographic Traits of Respondents

Of the 128 counselors in the sample, one hundred four (104) rehabilitation counselors returned the surveys. Ten surveys were deemed invalid because of insufficient data. Ninety-four (94) surveys were usable for describing the results for a return rate of 73%. Of this sample, 72 respondents (76.6%) were affiliated with NCDVRS, and 22 respondents (23.4%) with NCDSB. Approximately 58% of respondents were male. The mean years of experience was 12.55 with a SD of 7.95. About 57% had 11 or more years of work experience as rehabilitation counselors.

The mean age was 39.7 with a SD of 10.9 years. About 44% ranged between the ages of 24-40 years old, while 54% ranged between 41-60 years old. Eighty-four percent of the respondents were Caucasian and the remaining were Black. Only 20% had Native Americans on their caseloads. Thirty-one percent of the sample were familiar with Native American healing practices. The mean years of service provided by counselors to Native Americans was 4.31 with a SD of 7.22. The years of service ranged from 1-10 years (25%), 11-26 years (18%), while the majority of 57% did not indicate any years of service to this ethnic group.

Native American Healing Practices

The survey listed commonly used Native American healing practices and rehabilitation counselors indicated their belief on the effectiveness of each practice.

Over 80% of the sample were unfamiliar with each practice. A small portion of the sample believed some of the practices were somewhat to very effective, including: (a) use of a sweat lodge (14.2%), (b) ceremonies for purification of the spirit (8.7%), (c) visiting a native healer for counseling (8.7%), and (d) use of ointments, salves, and poultices made from herbs (12%).

About 3% believed it somewhat effective to use sassafras tea to reduce swelling in the feet/legs associated with diabetes (i.e., Mean = 1.30 and SD = .78). Three percent believed it somewhat effective in using special diets of sacred foods indicated by a native healer (i.e., Mean = 1.32 and SD = .78).

Several one-way ANOVA's for unbalanced data using the SAS general linear models procedure were conducted to analyze the data between the two groups. The significance level selected was p = .05. A significant F = 4.48 was found, df = 1/91, and p = .037, regarding differences between the two groups on their beliefs that services provided through state agencies were culturally appropriate for Native Americans with disabilities. There was a significant difference between the NCDSB counselors (Mean = 3.77) and NCDVRS counselors (Mean = 3.38) indicating that services provided by the state agency were culturally appropriate for Native American clients.

Discussion

Native American clients may not discuss cultural beliefs with non-Native counselors. Secondly, some Native American clients working with the counselors surveyed do not observe traditional native healing practices. Although Native American healing and cultural beliefs are believed to be important in a counseling relationship it appears that this sample was generally unfamiliar with Native American healing practices. The uncertainty of many counselors regarding cultural appropriateness of services may have resulted from limited experience working with this population and/or a lack of familiarity with the cultural beliefs of Native Americans.

Table 2

Rehabilitation Counselors' Beliefs on Effectiveness of Native American Healing
Practices N = 92

Use of Ginseng to Improve Vision            Frequency            Per cent

Unfamiliar with practice                        79                 85.9%
Not effective                                    3                  3.3%
Unsure                                           9                  9.8%
Somewhat effective                               1                  1.1%

Use of Sassafras Tea to Reduce Swelling
in Feet/Legs Associated with Diabetes

Unfamiliar with practice                        79                 85.9%
Not effective                                    1                  1.1%
Unsure                                           9                  9.8%
Somewhat effective                               3                  3.3%

Use of Yucca Roots, Mashed and Boiled
to Make a Tea for Treating Diabetes

Unfamiliar with practice                        82                 89.1%
Not effective                                    1                  1.1%
Unsure                                           8                  8.7%
Somewhat effective                               1                  1.1%

Use of Crystals to Absorb Negative Energy

Unfamiliar with practice                        81                 88.0%
Not effective                                    3                  3.3%
Unsure                                           7                  7.6%
Somewhat effective                               1                  1.1%

Use of a Sweat Lodge

Unfamiliar with practice                        74                 80.4%
Not effective                                    1                  1.1%
Unsure                                           4                  4.3%
Somewhat effective                              11                 12.0%
Very Effective                                   2                  2.2%

Visiting a Native Healer for Counseling

Unfamiliar with practice                        77                 83.7%
Not effective                                    1                  1.1%
Unsure                                           6                  6.5%
Somewhat effective                               7                  7.6%
Very Effective                                   1                  1.1%

Use of Ointments, Salves, and Poultices
Made from Herbs

Unfamiliar with practice                        75                 81.5%
Not effective                                    1                  1.1%
Unsure                                           5                  5.4%
Somewhat effective                               9                  9.8%
Very Effective                                   2                  2.2%

Use of Special Diet of "Sacred" Foods
Indicated by Native Healer

Unfamiliar with practice                        78                 84.8%
Not effective                                    2                  2.2%
Unsure                                           9                  9.8%
Somewhat effective                               3                  3.3%

Use of "Smudging," a Ritual using Smoke to Clear
Away Negative Energies and Attract Positive Ones

Unfamiliar with practice                        82                 89.1%
Unsure                                           8                  8.7%
Somewhat effective                               2                  2.2%

Ceremonies for Purification of Spirit

Unfamiliar with practice                        78                 84.8%
Not effective                                    3                  3.3%
Unsure                                           3                  3.3%
Somewhat effective                               7                  7.6%
Very Effective                                   1                  1.1%

The difference between the two groups regarding cultural appropriateness of services by the state agency may be attributed to two reasons. First, 28% of the rehabilitation counselors with the Division of Services for the Blind had one or more Native Americans on their caseloads contrasted with 19% of the rehabilitation counselors with the Division of Vocational Rehabilitation Services. Secondly, 55% of the rehabilitation counselors with the NCDSB had one or more years of service to Native Americans contrasted with 39% of the rehabilitation counselors with the NCDVRS.

The rehabilitation counselors in this sample had limited experience with Native American clients. This may be due to such a small number (174) on their caseloads. Currently, only about 24% have Native Americans on their caseloads, but over half of the counselors indicated having previously worked with Native American clients.

Although the rehabilitation counselors surveyed are generally unfamiliar with Native American healing practices, a majority agree that an awareness of Native American healing practices and cultural beliefs are important in working with Native Americans. Approximately 42% felt that they could benefit from training about Native American cultural beliefs.

Over half of the counselors surveyed were unsure if State rehabilitation services were culturally appropriate for Native American clients, and about 40% agreed that services were culturally appropriate. The uncertainty about State services being culturally appropriate and unfamiliarity with Native American healing practices, may result from the limited number of Native Americans being served.

Limitations

Limitations to this study included inability to generalize results beyond counselors in North Carolina. Additionally, results should be interpreted with caution due to the small sample size having experience with Native Americans.

Conclusions and Recommendations

The purpose of this study was to identify the perceptions of rehabilitation counselors about the use and effectiveness of Native American healing practices among their Native American clients. The results indicated that they believed an awareness of Native American healing practices was important in the rehabilitation counseling relationship and 42% desired training about Native American cultural beliefs.

The majority of counselors' unsureness about the cultural appropriateness of state rehabilitation services for Native Americans may stem from (a) the consumer's caution to divulge aspects of his/her culture in the counseling process, (b) the small number of Native Americans on caseloads and (c) the counselor's unfamiliarity of Native American healing practices and culture.

Increased counselor efforts to actively market services to this diverse target group and understand Native American healing practices may well contribute to the reduction of communication barriers and facilitate the achievement of clients' goals.

The difference between the two groups regarding the cultural appropriateness of state agency services may well be attributed to the rehabilitation counselors with the NCDSB having more Native Americans on their caseloads and more years of service to Native Americans than counselors with the NCDVRS.

Counselor perceptions of Native American healing practices are also important in meeting the principles of the Rehabilitation Act Amendments of 1992. These principles emphasize respecting individual dignity and self-determination to be an active participant in rehabilitation through meaningful and informed choices. Secondly, respecting the inclusion, integration and full participation of consumers culturally and socially with family involvement and natural supports may contribute to the rehabilitation program's success. Exploration by counselors about cultural issues of interest to improve services to Native Americans is encouraged.

Appropriate training approaches should be identified and facilitated by Native American and non-Native American trainers. Such training on cultural diversity could be incorporated into the counseling relationship.

Additional research is needed to identify perceptions about disabilities and treatment among Native American clients involved with state rehabilitation agencies.

Research on Native Americans may positively impact upon the counseling relationship in the areas of (a) enhancing counselors' cultural awareness about the diversity of Native American cultures, (b) facilitating trust and communication between the counselor and the consumer to minimize cultural barriers and (c) empowering clients to use aspects of their culture as an integral part of setting goals in the rehabilitation process to meet the spirit of the Rehabilitation Act Amendments of 1992.

Acknowledgements

The North Carolina Division of Vocational Rehabilitation Services and North Carolina Division of Services for the Blind were very supportive in providing suggestions and assisting in this study. We wish to express our sincere thanks to Mr. Claude Myer, Director of the NCDVRS, Mr. Herman Gruber, Director of the NCDSB, Mr. Joe Morrow, Assistant Director of Planning and Evaluation Services with the NCDVRS and Mr. George Parrish, Program Evaluation Specialist with the NCDVRS for their cooperation.

References

Avery, C. (1991). Native American medicine: Traditional healing. Journal of the American Medical Association, 265,(17), 2271-2273.

Becker, T.M., Wiggins, C., Peek, C., Key, C.R., and Samet, J.M. (1990). Mortality from infectious diseases among New Mexico's American Indians, Hispanic Whites, and other Whites, 1958-1987. American Journal of public Health, 80,(3), 320-323.

Chee, V. E. (1991). Medicine men. Journal of the American Medical Association, 265,(17), 2276.

Clark, S. & Kelley, S.D. (1992). Traditional Native American values: Conflict or concordance in rehabilitation? Journal of Rehabilitation, 58,(2), 23-28.

Heinrich, R.K., Corbine, J.L., & Thomas, K.R. (1990). Counseling Native Americans. Journal of Counseling & Development, 69, 128-133.

Hodge, F. (1989). Disabled American Indians: A special population requiring special considerations. American Indian Culture and Research Journal, 13, 83-104.

Hull, C.H., & Nie, N.H. (1981). SPSS Update 7-9. New York: McGraw-Hill.

Lange, B.K. (1988). Ethnographic interview: An occupational therapy needs assessment tool for American Indians and Alaska Native alcoholics. Occupational Therapy in Mental Health, 8(2), 61-80.

Marshall, C.A., Johnson, M.J., Martin, W.E., Saravanabhavan, R.C., & Bradford, B. (1992). The rehabilitation needs of American Indians with disabilites in an urban setting. Journal of Rehabilitation, 58(2), 13-21.

North Carolina Commission on Indian Affairs. (1990-1991). Annual Report. Raleigh, NC: Author.

O'Connell, J.C. (Ed.). (1987). A study of the special problems and needs of American Indians with handicaps both on and off the reservation, Vol. I. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center at Tucson, AZ: University of Arizona, Native American Research and Training Center. (Available from the American Indian Rehabilitation Research and Training Center, P.O. Box 5630, Flagstaff, AZ 86011).

Parrish, G.W. (1992). Program evaluation pertaining to Native Americans in North Carolina. Unpublished raw data. Available from The NC Division of Vocational Rehabilitation Services, Raleigh, NC.

Rehabilitation Act Amendments of 1992, Pub. L. No. 102-569, 106 Stat. 4344.

Schact, A.J., Tafoya, N., & Mirabla, K. (1988). Home-based therapy with American Indian families. American Indian and Alaska Native Mental Health Research, 3(2), 27-42.

Statistical Analysis System Institute, Inc. (1987). SAS/STAT guide for personal computers, Version 6 Edition. Cary, NC: Author.

Wright, T.J. (1988). Enhancing the professional preparation of rehabilitation counselors for improved services to ethnic minorities with disabilities. Journal of Applied Rehabilitation Counseling, 19, 4-10.

M. Ellen Braswell, MS, CRC, Division of Rehabilitation Counseling, Department of Medical Allied Health Professions at The University of North Carolina at Chapel Hill, CB# 7205 Medical School Wing E, Chapel Hill, NC 27599-7205