Traditional Native American values: conflict or concordance in rehabilitation?

The professional literature dealing with multicultural concerns suggests that effective service delivery and outcomes in health and human services depend upon cultural relevance and on the degree to which specific cultural values and service practices are aligned. This paper examines some traditional Native American values that pertain to rehabilitation programs in the contexts of communication, health care, and alcohol abuse. The need for rehabilitation professionals to reframe their perceptual orientations about Native Americans is emphasized as a viable mechanism to achieve concordance rather than conflict in the process of service delivery.

The goals of rehabilitation include independence, employment, and community integration (Wright, 1980). While these goals are achieved by many persons with disabilities in the dominant culture, rehabilitation efforts with Native Americans have had more limited success. Lack of understanding of diverse Native American cultures, which are widely disparate from the Euro-American culture, contributes to the difficulties encountered throughout the rehabilitation process by both counselors and Native American clients. Communication styles, social structures, and value systems unique to Native Americans are often contrary to the orientation and modes of operation of rehabilitation programs and professionals. These factors influence utilization and efficacy of services. Because the Native American population is increasing in both numbers and lifespan, and, concurrently, federal financial support for Native American programs is decreasing, the need for effective, culturally appropriate rehabilitation services is even more vital.

In keeping with the intent of the Indian Self Determination and Education Assistance Act Amendments of 1988, more responsibility for a broad range of human services is being shifted to tribal organizations (Pirtle, Morisset, Schlosser, & Ayer, 1988; Lonetree, 1989). In areas of concern such as physical health and alcoholism, it is paramount that attention be paid to the underlying values of Native American clients if rehabilitation goals are to be met. The substantial number of recent professional books and journal articles about Native Americans is not only indicative of an increased awareness, but also supports the necessity for a multicultural orientation to rehabilitation.

The purposes of this paper are (a) to examine some generalized Native American cultural values, (b) to look more closely at the effects of these values on service delivery in problem areas such as communication and learning, health care, and alcoholism, and (c) to provide examples of current rehabilitation programming within the context of Native American cultures.

Values of Native American Clients

Individual and tribal differences notwithstanding, there are generalized values which permeate all Native American cultures. Anderson and Ellis (1988), Oppelt (1989), Heinrich, Corbine, and Thomas (1990), Herring (1989), Sue (1981), Fischer (1991) Axelson (1985), and Thomason (1991) provided comparative analyses of these values and dominant culture counterparts. Native American values most pertinent to rehabilitation are: (a) Happiness and harmony between and within individuals, the society, and nature; (b) generosity in sharing of self, resources, and possessions; (c) transmission of knowledge through an oral tradition; (d) an orientation to the past which honors tradition, and to the present in taking life as it comes; (e) a fluidity of lifestyle which is without external constraints other than those voluntarily chosen; (f) work which is in harmony with the individual and meets present needs; (g) discrete and respectful communication with little eye contact and an emphasis on listening; and (h) a universal spirituality which is integral to all life and every lifestyle. These are all functional values with which the planning and delivery of rehabilitation services should be aligned. Functional values need to be considered among the strengths of clients and employed to enhance service delivery in all phases of the rehabilitation process.

Trimble (1981) and Matheson (1986) state that the challenge in effectively counseling Native Americans is not only having the ability to recognize tribal and individual variations in both values and degree of acculturation to Euro-American society, but also in employing timely and appropriate communication strategies such as non-directive approaches. Recognition of the physical and cultural diversity among Native Americans should preclude premature labeling of attitude, affect, and aberration. Too often Euro-American ethnocentricity creates erroneous stereotypes and diagnoses. The frustration of miscommunication engendered by disparate orientations affects both clients and counselors and is an impediment to establishing rapport and sound working relationships. Rehabilitation counselors may find that traditional one-to-one, insight-oriented counseling is not sufficient for Native American clients. Enlisting the help of Native American advocates, however, may bridge the perceived chasm between counselors and clients.

Attneave (1982), Ho (1987), and Light and Martin (1986) discussed Native American values within the family unit. A major problem in achieving a multicultural system is that too often the focus of programs is on the predominating limitations and disabilities which are perpetuated within families rather than emphasizing and utilizing the strengths inherent in them. Because many Native American families view rehabilitation as a family-centered rather than client-centered affair, comprehensive rehabilitation plans that include disability-targeted programs for individual clients can serve as an appropriate enlistment point for family support (Marshall, Martin, Thomason, & Johnson, 1991).

Special Value-Laden Problems for Service Delivery

Communication and Learning

Communication is the essential ingredient in education, counseling, rehabilitation, and in the world of work. Over 150 Native American languages exist today. Except for adopted words and phrases, none bears any similarity to English in either concept or construction. Dominant culture assumptions of the clarity and intent of verbal English communications may not be shared by clients whose mastery of English as a second language is rudimentary and literal. For these clients, the education and extratribal acculturation process may be difficult, humiliating, and even impossible. Tanner and Martin (1986) pointed out the impact of limited English proficiency throughout the lifetime of a Native American. Adult Native Americans show reading and expressive English deficits which interfere with traditional rehabilitation evaluation and counseling strategies; these deficits may have even higher impact in the English-speaking work place. The accurate identification of language-learning problems, communication disorders, and cognitive deficits requiring special education is a perennial challenge to educators of Indian children (Attneave, 1985); via planned transitions from school to work or vocational education, some of these students will become rehabilitation clients.

According to Langford and Riley (1986), reading of English is still directly related to two factors, cultural relevance of the material and the concept/construction pattern of the first (Indian) language. Interpreters may help to bridge linguistic chasms, but cross-lingual or severely limited English communication may become oversimplified or distorted in translation. Without adequate language support, some Native American workers may lose jobs, not because of skills deficits, but because of the inability to comprehend work place language.

Sidles and MacAvoy (1987) and Lonner (1981) rated limited English proficiency as the primary confounding factor in obtaining accurate measures of the verbal ability of Navajo adolescents. They also felt that the choice of assessment instrument plays a crucial part. These authors urged the use of the Raven Progressive Matrices, a nonverbal test that has been normed for a Navajo population, as well as for others, and is more closely representative of the conceptual constructs in Navajo thought patterns and learning styles. Lonner felt that an understanding of underlying conceptual constructs is vital to valid interpretation of test results. In an effort to provide better evaluations for Native American clients, several tribal vocational rehabilitation programs are currently considering using the Raven instrument in vocational assessment (B. Noggle, personal communication, September 19, 1991; L. Alflen, personal communication, July 9, 1991; M. Lundy, personal communication, January 29, 1991).

Native American learning styles have been researched by Griggs and Dunn (1989) who found that the preferred style is a visual/spatial format in a relaxed, informal, cooperative setting, preferably with bright lights. According to these authors, verbal learning is facilitated by an interactive oral/aural method which is more effective with Native Americans than writing or reading assignments. Rehabilitation programs' increasing use of situational and functional assessment, as well as community-based assessment and adjustment services, accommodate Native Americans' distinctive learning styles to a greater degree than traditional vocational evaluation approaches which rely more on didactic techniques. More accurate ecological assessments of actual vocational potential may be obtained in this way and vocational training can then be adapted to suit learning styles.

Health Care for Native Americans

Native American societies employ a social view of illness, a holistic perspective, while medicine has relied upon the psychomedical/autonomy paradigm. The biomedical orientation to illness may disregard important contributing factors and adjunct healing resources for Native Americans. Understanding cultural values and behaviors related to illness in Native Americans can help professionals facilitate compliance and more effective treatment.

Native Americans are living longer; for those born between 1979 and 1981, life expectancy is 71.1 years. Many diseases that effected Native Americans' morbidity and mortality in the past, while not eradicated, are less prevalent; however, lifestyle-related accidents and chronic illnesses, such as diabetes, still represent major problems for health care providers (Indian Health Service, 1984). Health care for Native Americans has begun to shift from a medical/curative approach to a more balanced, shared responsibility between patient and medical practitioner. Education and community involvement in health management, including recreation, are new directions for the Indian Health Service (IHS) and are becoming more closely aligned with traditional Native American holistic views of illness prevention. Some IHS hospitals arrange referrals to traditional healers. The value of this balanced perspective as a factor in health is now reflected in IHS policy which acknowledges that the goals of meaningful employment and enhanced self-esteem are important elements of a wellness orientation for Native American health (Rhoades, Hammond, Welty, Handler, & Amber, 1987).

For older Native Americans, the choice to utilize modern medical facilities remains a difficult one. In a discussion of value conflicts, McWhirter and Ryan (1991) observed that although some Native American consumers have found a way to combine holistic, traditional practices and Western medical care, guilt and uncertainty often accompany that compromise. Thomason (1991) indicated that the same is true for mental health clients. Rehabilitation counselors may be called upon to bring such value conflicts, or the resulting dissonance, to resolution (Marshall, Martin, Thomason, & Johnson, 1991).

Alcoholism and Related Disabilities

Alcoholism among Native Americans is one of the most serious social and medical concerns for service providers (Burns, 1982) and represents at least 25 percent of the primary disability category in tribal rehabilitation program caseloads (Lonetree, 1989). Not only is it a primary cause of mortality and morbidity, it contributes to domestic violence, family dissolution, and crime as well. It compounds interrelated social factors such as unemployment, poverty, and cultural diffusion. Socioeconomic conditions including poor health, unemployment, poverty, inadequate education, and resultant low self-esteem are both cause and effect in relation to alcohol abuse. Rhoades, Mason, Eddy, Smith, and Burns (1988) and Lamarine (1988) have studied both the data and the programs provided by the Indian Health Service and have concluded that alcohol abuse and related problems unequivocally represent the single most significant menace to Native American life and health.

Two interesting characteristics related to alcoholism that are unique to Native Americans are these: (a) although most drinkers range in age from 25 to 44, after age 40 there is a sharp decline in drinking, and (b) many former drinkers voluntarily join the ranks of the abstainers who constitute as much as 60 percent of this population. Although individual action to drink, to quit, or to abstain is left to individual choice, group structure and drinking patterns are altered as a result of these choices (Lamarine, 1988).

There is a higher incidence of female alcoholism in Native American populations. Almost half of Native American deaths due to liver cirrhosis are women in their child bearing years, ages 18 to 40. Fetal Alcohol Syndrome (FAS) affects a much higher number of Native American babies (6 times more than the general population) because of higher rates of maternal alcoholism (Steacy, 1989). Because almost 20 percent of some Native American newborns are afflicted with FAS, massive alcohol education and prevention efforts have been mounted in Native American communities. Tribal programs have had more success than governmental ones in reducing prenatal drinking among pregnant women, but acceptance of drinking in Native American communities limits their effectiveness. As children with FAS grow into adulthood, they may present distinct and more frequent challenges for rehabilitation efforts.

Direct dominant culture programs and Indian alternatives have been employed in an attempt to find, pragmatically, anything that works. For example, the traditional Alcoholics Anonymous approach has proved to be incompatible with several strongly held Native American traditional values. Among these are not admitting personal weakness, not making public confessions, and not drawing attention to oneself. Marginally literate Native Americans, whose culture relies on songs, stories and legends for guidance, have been unwilling and often unable to make use of the mass of printed materials offered by AA (Grobsmith, 1989). Only highly acculturated urban Native Americans seem to benefit from typical AA programs. Some Native American modifications of the AA approach have met with success, however, Jilek-Aall (1981) observed that elements such as equality, lack of authoritative leadership, and the freedom to attend or leave have been incorporated into Native American AA groups. Diverse Native American spiritual values, cultural activities, and distinctly social components have been substituted or added. Native American sponsors have served as role models and community mentors.

Other treatment programs are also more successful with this population. Cohen, Walker, and Stanley (1981) reported on the Seattle Indian Alcoholism Program (SIAP). This program, comprehensive in approach, incorporates identification and referral, detoxification, intensive inpatient treatment, intermediate rehabilitation, outpatient treatment, outpatient followup, and criminal justice outreach. Although programs with these elements are common, SIAP is unique in that American Indians designed and implemented the program based on their own perceptions of needs. This is a model interdisciplinary program which draws as much on anthropology as on the science of medicine. By SIAP definition, alcoholism is a social disease. Medical assistance and referral are facilitated by close ties with the Seattle Indian Health Board. SIAP's culturally sensitive service providers, who work solely with Native American clientele, devote more attention to the social, cultural, familial, and ecological influences which figure so prominently in Native American alcoholism. Through its multimodal and social orientation, SIAP has met with better success than similarly structured dominant culture programs, in part because its emphasis is on Native American culture and values.

Recent research has pointed out the need for multifaceted and multicultural approaches to education, prevention, and treatment in order to gain control over alcoholism among Native Americans. Mitchell and Patch (1981), Lamarine (1988), Rhoades, Mason, Eddy, Smith, and Burns (1988), Mitchell (1982), Nofz (1988), and Hill (1989) noted the historical lack of prevention and education efforts in working with Native American alcoholics. It has been shown repeatedly that alcoholism is a familial, social, and cultural phenomenon as well as a physical disease, yet only recently has attention been directed toward early, inclusive intervention. A major factor in the Indian Health Service's recent success has been the emphasis placed on alcohol education and prevention within a cultural context and on new programs to promote wellness. Individual tribes have been working with the IHS to create culturally appropriate treatment programs and to assume more responsibility for alcohol education.

According to Hill (1989), treatment plans must be flexible enough to identify and selectively help both clients and families. Sociocultural factors such as tribal affiliation, degree of acculturation, and present cultural context all bear heavily on the success of treatments and must be taken into account as well. Treatment plans may, or may not, include vocational rehabilitation services; but, individualized rehabilitation plans for Native American clients with alcoholism should include culturally-relevant treatment models such as those promoted by SIAP and IHS. Counselors should involve families and communities and should emphasize and utilize the cultural value of cooperative support.

Tribal Vocational Rehabilitation Projects

American Indian tribal vocational rehabilitation agencies were established under the 1986 Rehabilitation Act, as administered through the National Institute for Disability and Rehabilitation Research (NIDRR), because of the disproportionately high number of Native Americans with disabilities and the correspondingly low number of placements by state vocational rehabilitation (VR) programs. These projects espouse the same rehabilitation goals as the dominant culture programs; however, the tribal programs tend to attribute successful outcomes to culturally relevant services.

Lonetree (1989) examined 14 Section 130 American Indian Vocational Rehabilitation projects to determine training and technical assistance needs. The two areas in which staff training was most needed were development of Individualized Written Rehabilitation Plans (IWRPs) for Native American clients and information about medical aspects of disabilities. Among Lonetree's recommendations were: (a) American Indian VR staff, tribal officials, and community or tribal members should be involved as advisors or advocates, (b) state VR personnel should receive more exposure to multicultural perspectives, and (c) tribal members and VR agencies both need to understand values and cultural attitudes toward disability as they relate to VR services. Collaborative training workshops are being presented currently among tribal VR projects as part of an ongoing effort to address these issues and upgrade service delivery. These workshops also serve as a means for Native American and non-Native American project staff to align their cultural paradigms (M. Hermanson, personal communication, September 17, 1991).

Conclusion

Trimble and LaFromboise (1985) and Marshall, Martin, Thomason, & Johnson (1991) have noted that relatively few Native Americans attain professional status, but that many indigenous paraprofessionals may be found in health care, mental health, care rehabilitation settings. Trimble and LaFromboise (1985) maintain that non-Native American professionals have limited effectiveness, in part because of disparities in values orientation, and that until the Native American perspective is well-represented and respected, dominant culture views will remain suspect for they are perceived to represent Euro-American ethnocentric notions. Native American values present several challenges to many of the basic assumptions and modes of operation of dominant culture rehabilitation programs. It seems imperative that rehabilitation counselors relinquish adherence to traditional counseling and coordinating patterns and reorient themselves to make the best use of the resources inherent in the Native American culture and to locate or provide culturally relevant services (Marshall, Martin & Johnson, 1990; Fischer, 1991; Thomason, 1991). Acknowledging cultural diversity as valid, demonstrating greater sensitivity to Native American values, can actually expand rehabilitation counselors' range of service options and resources.

The Section 130 projects are a beginning; however, in all VR programs, a values orientation must permeate policy and practice so that non-Native American professionals and Native American consumers can work toward common goals. The task for non-Native American professionals is to accept that Native Americans should not be expected to completely relinquish traditional values in order to become self-actualized or self-determining. Instead, rehabilitation efforts should be aimed at utilizing those values to the clients' benefit as a form of adaptation.

An example of how rehabilitation efforts mediated a potentially conflicting situation is represented in the following situation: John, age 26, a Native American rehabilitation client, wanted to participate in Native American community spiritual ceremonies lasting several days. His non-Native American employer viewed this as a "flimsy excuse" for missing work and advised John that his absence would be cause for dismissal. John's rehabilitation counselor mediated this conflict by arranging for cultural leave with the employer. This strategy allowed John to retain an acceptable attendance record at his work site, yet respected his cultural values. This example illustrates how Native American values previously perceived as conflicting can be reframed and rendered concordant within the rehabilitation context.

In conclusion, it is important to recognize that learning about Native American cultures and values is an ongoing and enlightening process. As activities and outcomes of the Section 130 projects evolve, rehabilitation efforts can be modified to more effectively meet Native Americans' needs. In the interim, responsibility rests with rehabilitation service providers presently in place to be creative and resourceful in identifying and reorienting to value systems which enhance culturally compatible outcomes.

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