Using reasons for living to connect to American Indian healing traditions.

Responding to high rates of suicide for American Indian youth, helping professionals often struggle to connect healing traditions from American Indian cultures to tools from European psychology. The differences between American Indian healing and European therapy can be vast. Finding connections or building bridges between these two perspectives may be more difficult than it appears (Duran & Duran, 1995). One method to bring together these worldviews is to use the Reasons for Living Questionnaire (RFL, Linehan, Goldstein, Nielsen, & Chiles, 1983); the Reasons for Living Inventory for Adolescents (RFL-A, Osman, Downs, Kopper, Barios, Besett, Linehan, Baker, & Osman, 1998), or other psychological assessments developed using the RFL as a foundation.

Reasons for Living (RFL) assessments have emerged as powerful strength based tools for assessing suicide risk (Range & Knott, 1997). RFL and RFL-A factors link to a relational worldview common to most American Indian people. A relational worldview considers a balance between forces often identified as spirit, context, mind, and body (Cross, 1998).

Using RFL or RFL-A in suicide assessments allows practitioners to assess where youth may be out of balance in one or more of the four traditional areas: spirit, context, mind, and body. This may assist specific referrals to culturally appropriate healing. RFL and RFL-A assessments could be augmented to improve their correspondence to the relational worldview.

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Western approaches to care have not been widely embraced by American Indian populations, and almost any type of mental health treatment tends to have disappointing results with American Indians (Husted, Johnson, & Redwing, 1995). Meanwhile, American Indian communities and mental health practitioners acknowledge that the need for mental health treatment is high. Perhaps the most dramatic illustration of this need is the high rate of suicide among American Indian youth. This rate is well established and has continued for decades to be more than double the national rate for non-Indian youth (Grossman, Milligan, & Deyo, 1991).

To understand American Indian perspectives on causes for the high rate of youth suicide and the need for traditional healing, it will be important to review American Indian history. To describe some of the most common American Indian perspectives of wellness and balance, the relational worldview (Cross, 1998) will be presented. Next, tools for suicide assessment especially the Reasons for Living Questionnaire (RFL, Linehan, Goldstein, Nielsen, & Chiles, 1983) and the related Reasons for Living Inventory for Adolescents (RFL-A, Osman, Downs, Kopper, Barrios, Besett, Linehan, Baker, & Osman, 1998) will be presented. The RFL and RFL-A will be linked to the relational worldview and indigenous healing approaches. Finally, areas where the reasons for living assessments could be further developed for use with American Indian adolescents will be discussed along with cultural guidelines for assessment and intervention with potentially suicidal American Indian youth.

History

The history of American Indian people is survival in the face of mass destruction. Estimates about the number of American Indians in North American before European contact range from two million to as many as 18 million (Shoemaker, 1999). There were at least 600 different indigenous groups on the scene and there were probably between five and ten million American Indians in what are now the United States and Canada (Nichols, 1998). Indigenous people in North America lived in cities and villages, long houses and kivas, and had social organizations including families, clans, and nations. Millions of people and their homes, families and nations had to be eliminated to make room for European colonization.

Colonization destroyed and demeaned traditional ways of indigenous people (Duran & Duran, 1995). This also meant destruction of methods of economic survival, destruction of family systems, and overt and covert genocide (Tafoya & Del Vecchio, 1996). Between 1500 and 1900, the death rate for indigenous peoples in North American was considerably higher than the birth rate. American Indians died by the millions from disease, wars of extermination, and reservations and boarding school conditions comparable to concentration camps.

By the 1880s, United States policies started to switch from tactics of annihilation to strategies of assimilation. American Indian children were the primary targets of this policy shift. Indian agents forcibly removed American Indian children from their families and placed them in boarding schools. They did so because they saw the "Indian problem" where indigenous people fought to keep their own ways as a problem of cultural differences. They wanted to replace "every aspect of traditional native culture" with "the institutions of a `higher' society" (Trennert, 1983, p. 268).

Parents and grandparents of the American Indian adolescents of today experienced the Termination Era between 1946 and 1968. This was a time of federal laws attempting to terminate federal responsibility toward Indian tribes and to assimilate Indian people (Beane, 1989). In 1953 House Concurrent Resolution 108 called on the BIA to begin terminating tribes. Public Law 83-280 (1953) was enacted as a means of implementing the termination policy and giving states more jurisdictional power (Nichols, 1998; Beane, 1989). During the termination era, the Bureau of Indian Affairs (BIA) relocated approximately twenty thousand Indians from reservations to cities to find jobs, but most of the new work was in seasonal and low-skilled positions (Nichols, 1998). Many American Indian people were forcibly relocated to large metropolitan areas including Seattle, San Francisco, and Los Angeles. Families were promised housing, jobs, and other support, but the reality was that they were left to fend for themselves in cities with no support. They were given no training (Beane, 1989; Duran & Duran, 1995). Families who survived this continue to experience the effects of this forced relocation with symptoms identical to refugee and concentration camp syndrome (Duran & Duran, 1995).

Between 1960 and 1980 Indian groups in the United States began to take militant stands against government policies (Nichols, 1998). Since 1968, Federal Indian laws have largely supported policies of self-determination. American Indian leaders have campaigned for policies to reaffirm the rights of Indians to remain Indian while exercising their rights as Americans (Beane, 1989).

Historical Trauma, Loss and Suicide

While American Indian people survived policies of annihilation and assimilation, lasting scars have been left. Historical trauma for American Indian people is similar to trauma for other historically oppressed groups with important common features--"difficulty in mourning a mass grave, the dynamics of collective grief, and the importance of community memorialization" (Brave Heart & DeBruyn, 1998, p. 61). This history is painful to recall and more painful when it seems to be forgotten, trivialized or denied.

The effects of historical trauma add a layer of distress for Indian youth, above and beyond the other factors leading to adolescent suicide. A growing body of evidence suggests factors that are related to suicide for American Indian teens. While reviewing some of these research findings, it is important to keep in mind a caution from Mays and Dizmang (1974) against over generalizing conclusions about suicide across tribal groups," ... each tribe has its own uniquely evolved way of life and, consequently, a wide variation in suicide rates" (p. 23).

Research into suicide attempts for Navaho youth highlight factors related to suicide for many indigenous youth. Histories of physical abuse and sexual abuse are two of the key factors associated with suicide attempts for Navaho youth (Grossman, Milligan, & Deyo, 1991). Other factors associated with Navaho youth suicide are histories of mental health problems, alienation from family and community, poor self-perception of health, weekly consumption of hard liquor, a family history of suicide and parasuicide, and having a friend who attempted suicide (Grossman, Milligan, & Deyo, 1991).

For American Indian youth from multiple tribes in a boarding school setting, Manson, Beals, Dick, and Duclos (1989) found a strong association between relatives or friends committing suicide and current risk of suicide. Depressive symptoms were strongly related to past suicide attempts and current risk for suicide. Alcohol consumption, stressful life events, and little support from family were other associated factors (Manson, Beals, Dick, & Duclos, 1989).

Davenport and Davenport (1987) propose that two forms of suicide defined by Durkheim, altruistic and anomic, are most applicable to American Indians. The third type egoistic suicide, stemming from excessive individualism is rarely applicable. Altruistic suicide is a tendency for an individual to sacrifice self for the group, and anomic suicide is a response to social change whether good or bad. Whenever there is social change, anomie, a state of normlessness, increases (Davenport & Davenport, 1987). Manson, et al., (1989) report American Indians who committed suicide typically belonged to tribes with loose social integration that were undergoing rapid socioeconomic change. High rates of suicide among Apaches in New Mexico from 1980 to 1987 may relate to low levels of social integration and low band solidarity (Van Winkle & May, 1993). Lester (1995) found high rates of poverty were highly correlated with suicide rates for Apaches, Navajos and Pueblo Indians in New Mexico, suggesting the high rate of poverty in Indian country is a reason for high rates of suicide attempts.

Suicide can also be explained as a result of internalized oppression (Duran & Duran, 1995). Internalized oppression occurs when American Indian youth accept negative stereotypes of themselves common in the media and blame themselves for problems associated with racism and oppression. Cultural supports can help youth become familiar with positive images of American Indians and positive images of themselves. On the other hand, a factor leading to the higher suicide rates for American Indian youth is their loss of culture or the destruction of culture that would have sustained them (Duran & Duran, 1995). Dinges and Duong-Tran (1993) in a survey of 124 boarding school youth found loss of cultural supports was associated with depression, suicide ideation, and suicide attempts.

Solving problems of cultural loss and anomie for potentially suicidal youth involves finding a balance between their traditional ways and the pressures and demands of the surrounding society. Allen C. Quetone, Kiowa, described this challenge for raising American Indian children, "While we believe these traditional ways could serve as guidelines for our future and bring us happiness, we face great frustrations. Our ways seem always to contradict the ways of the dominant society. We find hardship in trying to be Indian and true to our beliefs and at the same time trying to survive in the mainstream of modern life" (Morey & Gilliam, 1974, p. 147).

A comparable task faces helping professionals who want to assist potentially suicidal youth. To develop healing strategies, practitioners will need to be able to connect their knowledge and skills with American Indian worldviews about healing. Tafoya & Del Vecchio (1996) suggest practitioners will need to be able to help American Indian youth to identify elements of personal mental health and well-being and to design their own model based on health traditional values and practices. They will also need to assist American Indian youth to find appropriate methods to discharge anger, shame and fear associated with oppression and historical trauma (Tafoya & Del Vecchio, 1996). To do this, helping professionals will need to have a basic understanding of healing traditions presented here as a relational worldview. With a basic understanding of this worldview, they may be able to use a reasons for living assessment to help connect youth to traditional healing.

Relational Worldview

Terry Cross (1998) speaks and writes about a relational worldview common to most American Indian people. The relational worldview perceives health and wellness as a balance of four major factors, which can sometimes be understood as the spirit, the context, the mind, and the body. In different tribes and different cultures, these four factors or four directions may have different designations and corresponding but not exactly the same meanings. Voss, Douville, Little Soldier, and Twiss (1999) present an important journey into traditional Lakota philosophies and tradition with far more depth than the overview of intersecting tribal beliefs presented here. Poonwassie and Charter (2001) go through indigenous symbolic cyclical interpretations of life and universal connectedness including The Medicine Wheel, The Wheel of Life, The Circle of Life, and The Pimaatisiwin Circle. Among the four parts of these circles are physical, mental, emotional and spiritual elements, four directions North, East, South and West and other aspects of interdependence and harmony (Poonwassie & Charter, 2001). Duran and Duran (1995) describe a paradigm with thinking, feeling, and intuition/sensation balanced by a "hole or `emptiness' that is possible to walk into the transcendent with awareness and knowledge which is given by the spirits of all creation" (p. 78).

Understanding that important variations apply to this flamework, the relational worldview (Cross, 1998) provides a starting point. In the relational worldview, Spirit includes spiritual practices and teachings, dreams, symbols, stories, gifts, intuition, grace, protecting forces, and negative forces (Cross, 1998). Context includes family, culture, work, community history, and environmental factors including climate and weather. Mind includes intellect, emotion, memory, judgment, and experience. Body includes chemistry, genetics, nutrition, substance use and abuse, sleep and rest, age and condition (Cross, 1998). For American Indian peoples, the spiritual presence at each of these directions gives a specific type of wisdom, teaching, and relationship to the world (Duran & Duran, 1995).

Of course, these descriptions of these factors and their contents are only examples and do not represent the whole relational worldview (Cross, 1998). This is only a glimpse of spirituality for American Indian people; it is not a whole knowledge base to use in spiritual healing or treatment interventions. The goal of this description of relational worldview is to provide a sense of what types of forces need to be in balance for an American Indian person to experience a sense of well-being. Further use of the four elements of the relational worldview will be made following a description of reasons for living assessments.

Reasons for Living

The first reasons for living instrument was designed to provide an assessment process to understand life affirming and adaptive characteristics endorsed by people who were not suicidal and potentially lacking for people who were suicidal (Linehan, Goodstein, Nielsen, & Chiles, 1983). This approach builds on European humanist psychology, especially the work of Frankl (1962). The Reasons for Living Inventory (RFL) by Linehan and associates started a series of investigations into use of reasons for living as an assessment approach. Following the RFL, a number of assessment tools were created to ascertain reasons for living in different populations. There is a Brief Reasons for Living Inventory (Ivanoff, Jang; Smyth, & Linehan, 1994), a College Student Reasons for Living Inventory (Westefeld, Cardin, & Deaton, 1992) and the Reasons for Living Inventory for Adolescents (RFL-A, Osman, et al., 1998). These questionnaires can provide important information to mental health providers in their assessment of potentially suicidal youth or adults.

The RFL (Linehan, et. al., 1983) and RFL-A (Osman, et. al., 1998) are the main assessment tools described in this article. While the RFL was developed for use with adults, it has been tested with adolescents and found to be useful to clinicians in a variety of settings (Cole, 1989; Ellis & Russell, 1992; Pinto, Whisman, & Conwell, 1998; Range, Hall, & Meyers, 1993). The RFL-A was specifically designed for use with adolescents. Clinicians will want to know the reliability and validity of these instruments. For adolescents, a slightly modified version of the RFL was found to have convergent validity because RFL subscales were correlated with scales of depression, hopelessness, and other suicide inventories (Cole, 1989). Evidence of discriminant validity emerged in low correlations with social desirability. Evidence of construct validity emerged when the RFL subscales were related to suicidal thoughts and behaviors over and above scales measuring depression and hopelessness (Cole, 1989). When slightly modified, the subscales of the RFL are reliable for adolescents with coefficient alphas from .72 to .98, and a coefficient alpha for the total RFL of .97 (Pinto, Whisman, & Conwell, 1998).

The RFL-A scales have high reliability with coefficient alphas from .92 to .95 (Osman, et. al., 1998). Construct validity for the RFL-A is shown by moderate and significant correlations with hopelessness scales and depression scales (Osman, et. al., 1998).

In a review of 20 suicide assessment instruments, Range and Knott (1997) suggested use of Linehan's Reasons for Living Inventory (RFL) (Linehan, et al., 1983). One of the reasons for this recommendation is that people completing the RFL tend to feel more hopeful rather than more depressed after completing it. This benefit has been shown to occur cross culturally. A sample of Turkish respondents asked for a copy of the RFL because just reading it made them feel better (Sahin, Batigun, &; Sahin, 1998).

An evaluation of the clinical usefulness, validity and reliability of the RFL and RFL-A with American Indian adolescents has not been made. The author has limited positive experience using the RFL to assess and assist youth in crisis and to assist adults struggling with chronic depression and suicidal thoughts. Presenting the RFL has been useful to engage American Indian child welfare workers and Canadian Aboriginal mental health and child service specialists in discussion of suicide and approaches to provide healing opportunities for potentially suicidal youth. Life affirming aspects of the RFL and RFL-A have helped to balance experiences these professionals have had with suicide, loss, and despair. Indian Child welfare workers and mental health specialists have requested additional materials or informally reported their plans to take the instruments back to their communities with plans to adapt the RFL and RFL-A to the needs and cultures of their people.

To understand what the RFL and RFL-A have to offer, subscales of these instruments will be explored as they relate to the four directions of the relational worldview. This process will also indicate areas where a reasons for living assessment could be better adapted for American Indian youth. Reasons for Living (RFL) assessment approaches may help to introduce issues of spirituality, as well as other relational worldview factors including connections to family, hope for the future, and community support (See Figure 1).

[FIGURE 1 OMITTED]

Spirit

American Indian Child welfare workers and American Indian community leaders emphasize the importance of spiritual connections as a primary focus for suicide assessment, prevention, and intervention. Research also emphasizes the importance of spirituality to decrease suicide attempts and decrease self-destructive feelings (Ellis & Smith, 1991).

Through an assessment of an American Indian youth's spiritual beliefs, it may be possible to recognize when interventions and supports are necessary to prevent suicide. Often, the challenge for mental health or social service workers is how to bring up the topic in a productive fashion. Using the RFL instrument is one method to begin to draw out spiritual beliefs. The Moral Objections (MO) subscale of the RFL (Linehan, Goldstein, Nielsen & Chiles, 1983) includes spiritual considerations including "I believe only God has the right to end a life" and "I have a love of life."

Range and Knott (1997) and Sahin and colleagues (1998) find that the RFL does indicate religious beliefs against suicide for American and Turkish samples respectively. However, Range and Knott caution that "... therapists who use religion as a `Band Aid' when working with suicidal persons should be careful that the suicidal individual does indeed have religious beliefs" (1997, p. 60-61).

Range and Knott (1997) come close to the indigenous concept of balance when they write that, "spiritual beliefs alone may not be able to counter suicidal ideation over the long run, no one variable is responsible for suicide and no one variable is sufficient as an intervention when dealing with suicidal individuals" (p. 62). There is room for more exploration of American Indian traditional and spiritual resources beyond the items identified on the RFL (Linehan, et al, 1993). In traditional views one possible cause of illness is loss of the soul from the body (Duran & Duran, 1995). Another belief about illness is theft or abduction of the soul by ghosts or sorcerers. Treatment comes from restoration of the soul by the healer. Both of these beliefs may be difficult to grasp for a Western helping professional and are not likely to be investigated by Western psychological instruments (Duran & Duran, 1995) or by reasons for living assessments.

McCormick (1997) conducted critical incident interviews with 50 participants from the First Nations of British Columbia and identified "establishing a spiritual connection and participation in ceremony" and "anchoring oneself in tradition" as two of the ten categories of healing (p. 177). Reasons for living questions about spiritual connections could include asking prayer, participation in ceremonies, and participation in sweat lodges. Questions about connection to tradition could include questions about participation in traditional American Indian events from Pow Wows to bead work (McCormick, 1997). Suicide prevention can stem from participation in cultural activities with spiritual associations. The Association of American Indian Affairs in New York, the Black Hawk Dancers from the Chitimacha tribe of Louisiana, and intertribal dance workshops in Los Angeles provide important cultural activities with spiritual links that can help prevent suicidal behavior by American Indian adolescents (Johnson & Tomren, 1999).

Context

The American Indian self, "... has more fluid and permeable boundaries and contents that not only include the individual, but more typically contain the family, extended family, tribe, or community as well. In traditional individuals, this self may be further enlarged to contain animals, plants and places as well as natural, supernatural, or spiritual forces" (Dana, 2000, pp. 70-71).

Family is a central part of context in the relational worldview (Cross, 1998). Families, relatives, relations, or kin provide interdependent and reliable support systems that harmonize resources and are a source of strength for adolescents. Families transmit rich histories and heritage, and provide strategies about how to cope with the dynamics of difference and oppression (Cross, 1998).

To draw on the full resources of families for healing, it is important to understand the extensive nature of traditional American Indian families. Family in this context often comprises households with several generations and includes lateral connections with aunts, uncles, and cousins who are related through blood, marriage, adoption, or custom (Red Horse, et al, 2000). An American Indian's sense of belonging depends on an understanding of his or her place or responsibility within an intricate web of kinship relationships (Red Horse, et al, 2000).

Victor Sarracino, speaking of the Laguna Pueblo way, said "The overall responsibility for teaching the various members of the family to respect one another stems from the grandmother and the grandfather. Our whole training in behavior starts from our grandparents" (Morey &Gilliam, 1974, p. 105).

The RFL (Linehan, et. al., 1983) includes questions to assess an adolescent's connection to family and family supports including "I have a responsibility and commitment to my family," and "I love and enjoy my family too much and would not leave them." The RFL-A (Osman, et. al., 1998) includes "Whenever I have a problem, I can turn to my family for support or advice" and "Most of the time my family encourages and supports my plans or goals."

In Indian country, the therapeutic relevance can be accomplished only by using a model that encompasses the whole community (Duran & Duran, 1995). The relational worldview recognizes that family exists within a larger community context and includes supportive relationships with peers and community members (Cross, 1998). The RFL-A (Osman, et. al., 1998) includes peer acceptance and support including "I feel loved and accepted by my close friends." The RFL (Linehan, et. al., 1983) includes fear of social disapproval including, "Other people would think I am weak and selfish."

The profound sense of connection and interdependence in American Indian communities helps members recognize that an adolescent cannot have a problem without a loss of balance for the adolescent and for the community. The peer acceptance and support subscale of the RFL-A (Osman, et al 1998) and the social disapproval scale of the RFL (Linehan, et al, 1983) highlight the importance of this social context for healing. Relatives and friends are traditionally an important part of the healing process in American Indian communities (McCormick, 1997). It is important to identify supports from relative and friends to be able to involve them in a positive role in a recovery process. Interconnections with family and community members imply that helping others as well as being helped is a part of healing (McCormick, 1997).

The need for healing for an adolescent, his or her family, and his or her community is explained by an understanding that the adolescent and community have lost the ability to be in harmony with the life process (Duran & Duran, 1995). An adolescent, his or her family, and his or her community are all part the life process. If one or all parts are out of balance, all parts (adolescent, family, and community) need to participate in the healing process (Duran & Duran, 1995).

The area of context not included in these RFL instruments is connection with nature. Establishing a connection with nature is an important part of healing. This includes being in or being with the natural world including going on a journey into the forest or desert. This may also include using natural substances such as water or smoke in ceremonies (McCormick, 1997).

Henry Old Coyote, a member of the Crow nation, explained, "The Crows are taught that everything you see has a purpose in this world and contributes something to life. There is a purpose behind everything; there is a force out there and that same force is responsible for all that surrounds you" (Morey & Gilliam, 1974, p. 138).

Mind

The mind or intellect is the area or focus for Western psychology. Western or European thought tends to have people living in their minds (Duran & Duran, 1995). American Indian people experience their being in the world as a totality of personality and not as separate systems within the person. They do not perceive their mind being separate from their bodies (Duran & Duran, 1995).

In the context of whole systems, mind and body together, it is important to understand and work with the thoughts and beliefs of American Indian adolescents. Scales from the RFL (Linehan, et. al., 1983) and RFL-A (Osman, et. al., 1998) related to mind or individual psychological beliefs can help practitioners and adolescents to understand how they think of themselves in the context of the world. These scales include future optimism (RFL-A), suicide related concerns (RFL-A), self-acceptance (RFL-A), and survival and coping beliefs (RFL). The survival and coping beliefs subscale of the RFL, which includes positive expectations about the future and a sense of self-efficacy or ability to cope with whatever life has to offer, appeared most strongly to differentiate between suicidal and non-suicidal adolescents in testing of 253 adolescents in a psychiatric hospital (Pinto, Whisman, & Conwell, 1998).

Answering these RFL questions may help adolescents make an important cognitive switch from thinking about reasons for dying to thinking about reasons for living. First Nations People of British Columbia identified involvement in challenging mental activities and setting goals from public speaking to algebra as potential activities to lead towards healing (McCormick, 1997). They also identified gaining an understanding of the problem as an important ability to recover from a life crisis (McCormick, 1997).

To strengthen the mind component of healing, a reasons for living approach may be used in a Talking Circle with American Indian adolescents. As described by LaFromboise and Low (1998), Talking Circles resemble conventional therapy groups. Participants form a circle and remain in the circle until the ceremony is complete. Sweet grass is burned to produce purifying smoke and provide direction for group conversation. Each participant is free to speak, and no one is allowed to interrupt. Often a sacred object is circulated, and the ceremony ends with a joining of hands in prayer (LaFromboise & Low, 1998). French (1997) describes the development of a Navaho Talking Circle for use in prevention curriculum. In this circle, adolescents can be asked to identify their own reasons for living. If they struggle with trying to come up with ideas, examples from a list started from the RFL or RFL-A may be provided. Questions that elicit reasons for living include asking adolescents if they have reasons for getting up in the morning, if there are things they are looking forward to today, tomorrow or during the week, or even reasons they have hope to go on living.

Body

Nutrition is an important element related to the relational worldview of the body (Cross, 1998). Traditional foods are an important part of traditional Eastern Cherokee approaches to treating mental health and substance abuse (French & Hornbuckle, 1997). Healing activities include participating in gathering and preparing sweet grass, huckleberries, and wild nuts. Health can be restored from participation in cultural, nutritional and ceremonial aspects of preparation of traditional breads and the special Eastern Cherokee yellow jacket soup (French & Hornbuckle, 1997).

The importance of exercise and self-care was another area of healing accentuated by First Nations People of British Columbia (McCormick, 1997). Care of self and body includes activities like taking a hot bath. Physical exercise is also included. Self-care is seen as a way to ensure that the physical dimension of self is in balance (McCormick, 1997).

The relational worldview perspective does suggest that reasons for living could be expanded to address issues of the body and physical health. Health concerns can be important deciding points in thoughts about living or dying. The RFL (Linehan, et. al., 1983) only includes fear of hurting the body or suffering pain, "I am afraid of the actual `act' of killing myself (the pain, blood, violence)."

Questions about health and exercise, as part of living would be helpful to American Indian youth. A total health perspective is demonstrated by the Cheyenne River Sioux fitness center and the Zuni Wellness center (Voss, Douville, Little Stone, & Twiss, 1999). These state-of-the art fitness gyms are directly connected to other tribal social services (Voss, Douville, Little Stone, & Twiss, 1999). Thus, American Indian youth can be connected in one place with physical, mental and health resources.

Balance

The clinical utility and import of Reasons for Living are powerful. Survival and Coping Beliefs, Responsibility to Family, and Moral Objections subscales of the RFL were able to differentiate suicidal from non-suicidal adolescents and adolescents who attempted suicide from adolescents who thought about suicide (Pinto, Whisman, & Conwell, 1998). Osman and colleagues (1998) report the RFL-A can be used with the Suicide Probability Scale (Cull & Gill, 1982) to differentiate between adolescents in psychiatric treatment for suicidal concerns and nonsuicidal adolescents. Adolescents who endorse reasons for living are more likely to have resiliency resources to help them avoid suicide, while adolescents who do not endorse reasons for living are more likely to attempt suicide.

While any reasons for living are better than no reasons, some reasons do seem to hold up over the long run. Avoiding suicide based on fear that the method will fail or that it will be painful tends to be a less successful strategy than believing one has a caring family (Linehan, et. al., 1983). Cole (1989) advises, "... clinicians might do well to be particularly concerned about suicidal adolescents who rely heavily upon fear of social disapproval as a reason for staying alive" (p. 25).

The RFL, RFL-A and other reasons for living assessments are important because they tap positive dimensions of a people's thinking instead of being focused on negative elements, problems or pathology (Range & Knott, 1997. Using the RFL or RFL-A leads to useful interventions because the assessment process indicates where adolescents have support and reasons to live, and where they need support when they are not finding reasons. The RFL and RFL-A begin an intervention because they cause an adolescents to spend time considering lists of reasons to live, and if they have been contemplating suicide, this may be a switch from time spent contemplating reasons to die.

Results from the RFL and RFL-A suggest that adolescents who have reasons for

living that cross multiple domains and spheres of influence seem less likely to commit suicide. In other words, it is healthier for people to live in balance and to have connections with friends, family, nature, and community members who care for them (Duran & Duran, 1995; LaFromboise, & Low, 1998; McCormick, 1997).

Conclusion

For American Indian people, a relational worldview perspective is usually central to their view of wellness and healing. One method of connecting European mental health approaches with American Indian healing perspectives may be to use a Reasons for Living assessment. Using these assessment tools, a practitioner could help American Indian adolescents assess where they may be out of balance and help them connect with traditional healing approaches to further support their growth.

Of course, a RFL or RFL-A assessment may lead a helping professional to an understanding of the need for traditional supports for an American Indian adolescent, but the helping professional will need to have connections with traditional healers who can provide that support. Therapists should refer to or consult with traditionalists at all levels of intervention (Duran & Duran, 1995).

During interactions with American Indian people, a helping professional can seek reasons for living in all four areas of the relational worldview. American Indian adolescents can be given homework to think of more reasons for living and to consult with, family members and elders about other important reasons for living including spiritual guidance. American Indians youth may be willing to take this approach since it gives them a positive way to connect with family members. Learning from a role model or connecting with a respected elder is an important part of American Indian healing (McCormick, 1997; Red Horse, et al, 2000). Asking about reasons for living helps them to focus on hope for success and less on their failings or problems.

RFL assessments could be augmented to improve their correspondence to relational worldview. Further work should be done to provide a better culturally specific starting point for these workers, including developing a reasons for living assessment specifically for American Indian youth. The enlightening aspects of spirituality should be included in Reasons for Living Instruments (Ellis & Smith, 1991). Questions about connection with nature could improve a sense of balance in the context area of the relational worldview (McCormick, 1997; Cross, 1998). Concerns about body could include positive aspects of self-care as well as avoiding harm (McCormick, 1997). Even missing these positive factors, Reasons for Living Assessments may be most helpful to discuss the presence or absence of important family and community interconnections for American Indian people. These interconnections are a central element in balance and healing (Black Elk, 1988; Cross, 1998; McCormick, 1997). Using reasons for living assessments is a useful exercise to help American Indian people heal through contact with positive aspects of their families, friends, communities, cultures, and spiritual bases.

Availability

The RFL is available from Marsha M Linehan, Department of Psychology, Box 351525, University of Washington, Seattle WA 98195.

The RFL-A is available from Augustine Osman, University of Northern Iowa, 334 Baker Hall, Cedar Falls, Iowa 50615-0505.

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Thomas L. Crofoot Graham School of Social Work Portland State University PO Box 751 Portland, OR 97207-0751 [e-mail]