Journal of Rural Community Psychology               Volume E6   Number 1   Spring 2003


Revisiting the Spirit: A Call for Research

Related to Rural Native Americans


Tarrell Awe Agahe Portman & Dorieanna Dewey



The research on multiculturalism has focused on Native American Indians (all tribal affiliations and Nations) as one homogeneous population. This approach has failed to consider "within group" differences both by affiliation and geographic context. For example, Native American Indian children who live and grow up in rural areas may be involved in many cultural activities such as pow wows, dances, ceremonial events, health fairs, and family cultural gatherings. This rural “Indianness” or manner of embracing cultural heritage may be far removed from the life ways of Native American Indians living on reservations or in urban areas. This difference may also manifest in the care and consideration of elders within rural Native American Indian communities. How are elders treated differently by families or tribal administration centers based on their living in rural contexts? What are the helping seeking behaviors of Native American Indians in various geographic contexts or by various tribal affiliations?


Statement of the Problem


Helping professionals as well as other community caregivers tend to view Native American populations from a stereotypical, homogeneous population rather than recognizing that within the modern context of rural, urban, suburban and reservation settings are a varied mix of people from different nations and tribal affiliations, each with their own unique sets of problems and needs. This not only stymies the delivery of needed services, it sends a message that fails to support diversity in research or a focus on "within group" differences based on both affiliation and geographic realities. It is time to put forth a call for research related to how Native American Indians face cultural issues within public institutions in rural contexts such as schools, health care facilities, and community/rehabilitation counseling agencies.


The following questions although not inclusive may begin the discussion or encourage researchers to conduct further investigations.




What is the social justice role of health professionals in promoting research and counseling services that are contextually relevant (rural, suburban, urban, and reservation) to Native American Indians?


Does the public health profession including mental health professionals maintain an obligation to advocate for American Indian children and elders? If so why does the research focus primarily on young to middle adulthood in the lifespan?


Are Native American Indian elders receiving appropriate counseling and health care services across all living contexts?


How are differences between socio-economic status, poverty and class being addressed among various groups of Native American

Indians living in rural, suburban, and urban contexts?

Understanding Native American Indians Help Seeking Behaviors


Help seeking behaviors related to health care of Native American Indians include seeking counseling services such as mental health, rehabilitation, substance abuse, and school counseling. Native American health care still falls well below all other US racial groups (Provan & Carson, 2000). These health care needs from US governmental statistics indicate mortality rates due to behavioral health concerns of alcoholism, accidents, suicide, and homicide are greater than the 1993 age-adjusted all race US population statistics (Indian Health Services, 1997). According to the American Heart Association, heart disease, accidents, diabetes and chronic liver disease are the leading causes of death for Native Americans (American Heart Association, 2000). Mental health issues are the fourth leading cause of hospitalization among American Indians 15 to 44 years of age and the fifth leading cause for ambulatory visits for indigenous peoples 25 to 44 years of age (Provan & Carson, 2000, p.  17).


Originally, the federal government established a program to provide health services to Native American Indian peoples through a treaty. However, today these Indian Health Service (IHS) facilities are located primarily near recognized Native American Indian communities in states with large Native American populations. Thus, Native Americans living in rural, suburban, and possibly urban areas must travel great distances to receive IHS services or utilize conventional health care services, which may create social and economic problems due to lack of fiscal support. An historical overview is necessary to explore sociological perspectives related to the need for more modern and inclusive research of Native American Indian counseling needs.


Historical Perspective


A critical examination of the existing literature must begin with an historical overview. Over the past 200 years Native Americans were given some of the most unwanted and unbearable lands, which are now called reservations, rancharias, settlements, tribal jurisdiction areas, and colonies. These lands are administered by the Bureau of Indian Affairs (BIA), which was part of the treaties offered to Native American Indians in exchange for protection and Indian rights (Rothenberg, 1998). Over 300 treaties promising adequate housing, education, and health care were made with Native Americans by the United States Government, none of which have been honored (Richardson, 1993).


With the destruction of Native traditions, attempted genocide, disease, and treaty-based agreements, the federal government found itself responsible for the health care and other provisions of Native American Indians. Indian Health Service (IHS)agencies, who are responsible for the healthcare needs of Native American Indians, were assigned to the war department in 1803 (Pfefferbaum, Pfefferum, Rhoades, and Strickland, 1997). IHS was then transferred to the Bureau of Indian Affairs (BIA) in 1849, again transferred to the Public Health Service (PHS) in 1955, and is now controlled through (PHS) by the Department of Health and Human Service (DHHS) (Pfefferbaum, Pfefferum, Rhoades, and Strickland, 1997). Improvements were made to IHS over the years through the, Indian Self Determination ACT of 1975, Indian Health Care Improvement ACT of 1976, and amendments were added in 1992 (Pfefferbaum, Pfefferum, Rhoades, and Strickland, 1997). These amendments relinquished more control of services to tribal governments, assuming they would have power over planning, operation, and administering the programs. Although IHS has maintained its function, the health status of Native American Indians is below average because of budget constraints (Pfefferbaum, Pfefferum, Rhoades, and Strickland, 1997).


Currently, Indian Health Services is responsible for assuring access to high quality care depending on need; to assist tribes in developing more control over services offered through training and management, assist Native American tribes in accessing entitled programs. In addition, IHS is responsible for inpatient and ambulatory clinical services, community and preventative medicine, manpower development programs, and health facility construction. Prevention, treatment, and rehabilitation services are offered on a more comprehensive level, which includes optometry, dental, drug and alcohol, mental health and referral service (Pfefferbaum, Pfefferum, Rhoades, and Strickland, 1997). The services provided through IHS focus on treaty lands not general geographic living areas, thus pushing Native American Indians to live on or near such areas to receive health care services.


Current Conditions


According to LaFromboise (1993), mental health providers lack recognition of the special needs of ethnic minorities. Cultural ignorance is the number one reason for drop out rates and underutilization of help seeking behaviors (LaFromboise, 1993). Awareness of issues is an important aspect that is often overlooked by health providers. Identifying issues unique to American Indian cultures and understanding that all tribes are diverse with respect to geographic area, language, customs, religions, and family structures is important (Brucker & Perry, 1998).


An examination of research related to Native American Indians is necessary to support the need for more diversified descriptive information in publications related to this population –especially geographic context and tribal affiliation.


Weaver (1999) reported on a 1995-1996 needs assessment conducted by Native American researchers with participants from a Native American reservation. Data were gathered from 13 focus groups that consisted of 3 to 25 participants and 23 individual interviews. The groups were asked about the agency services that were offered and how helpful they were. The result indicated 25% of the community including staff where unfamiliar with these services. Yet the number of people that stated the programs were helpful had never even used the services. While other members of the community stated that some programs were not helpful at all because of alienation, political divisions, and cultural insensitivity. Other reasons included lack of training and service delivery because of a limited number of qualified people. The lack of outreach and communication made helpful programs ineffective. This study presented the perspective of Native American Indians in a set geographic context (reservation) and found services need to be addressed by proactively seeking funding to meet these needs and not to offer services based on the most available types of funding (Weaver, 1999).


Another study (Earle, 1998) included 45 American Indian recipients of mental health services (neither tribal affliations nor geographic contexts were provided) and 6,064 White participants. This study revealed that Native American Indians differed greatly from their White counterparts. Demographic characteristics, attitudes, and differences within response rates of Native Americans and Whites differed. It is interesting to note findings from this study point out the definition of “who is Indian” has a great impact when seeking help, because of federal recognition. However, the study had only 45 Native Americans participating which was less than 1% of the entire sample. The author concluding that blood quantum was a significant indicator of help seeking behaviors appears to be far reaching. A study with more equally distributed population groups compared mental health using a questionnaire of 66 Native Americans and 93 White undergraduate students. White students were found more likely to associate with poor mental health rather than Native American students when having visions, communicating with spirits, guiding ones life accordingly, and seeing and hearing things that others do not see or hear were present. Because of the spiritual, cultural, and traditional contexts, Native Americans are more likely to be wrongfully diagnosed; this may affect help seeking behaviors (Earle, 1998). However, again tribal affiliations of the Native American Indian students are not provided or their geographic context is not supplied. This study ignores the spirituality differences found between tribal affiliations.


Another study was done to explore help seeking behaviors of Native American high school students. A total of 139 Native American Indian students were surveyed (Gates, Howard-Pitney, LaFromboise, 1996). Results show Native American Indian boys and girls differed in that boys tended to seek help from their family (parent, friend, or relative), outside resources (teachers, counselors, and school staff), or no one (most often reported). Girls chose to seek help from a parent (most often reported), a friend, no one, and a teacher. Most of the students turned to outside sources of help for academic and career rather then personal reasons. Only one person reported using community resources such as Indian Health Services. High self-esteem was found to be a barrier to seeking help from community and other helping professionals and was a factor in reduced help seeking behaviors. These findings may be related to perceiving help seeking outside of the native communities as a sign of weakness. An indication that many Native Americans are seeking help either through traditional healing practices such as medicine men or women or spiritual healing through various ceremonies was also given (Nadler, 1983; Gates, Howard-Pitney, LaFromboise, 1996). This reference provides insight into the cultural behaviors of Native Americans. Culture includes those values, beliefs, perceptions, and traditions that are learned or socially acquired. Processes of thinking, feeling, or acting, which is patterned or repetitive, are also included (Harris, 1987; Haviland, 1989). This study relied on context and tribal affiliation as an underlying premise but calls for more insight into acculturation.




Acculturation must be understood when considering Native American Indians living in rural, urban, or suburban geographic contexts. Acculturation may be defined as "the process by which an individual is assimilated into the majority culture" (Zimmerman, Ramirez-Valles, Washienko, Walter, & Dyer, 1996). However, Coleman (1997) defined acculturation as an individual’s "affiliation with a second cultural group while realizing they [sic] are not a full member" and assimilation as an individual becoming "a full member of a second group" (p.  196). In Native American cultures this process was forced, and pressure to conform to the views of the dominant culture is strong (Heinrich, Corbine, & Thomas, 1990). The term “enculturation” is used to depict the forced movement of one group when oppressed by a second cultural group.  “Acculturation” is viewed as voluntary movement toward assimilation (Herring, 1997). 


When dealing with any group of Native American Indian clients, gaining an understanding of their level of acculturation is necessary. Acculturation for Native American Indians is not a positive aspect, because it is a reminder of forced assimilation, and the loss of traditions and values (Atkinson, Morten, 1998). It means conforming to the dominant culture, which goes against many Native American values and traditions. This conforming leaves many Native American Indians living in two worlds separated between their own ethnic communities and mainstream society, which creates an even bigger problem when seeking help (Moran, 1999). A study conducted to measure ethnic identity of 1,992 students representing 31 tribes and 55. 4% of the total Native American population reported on the 1980 census reported that ethnic identity is a critical component and has a large impact on psychological functioning in society (Moran, 1998). Having to live in two worlds causes Native people to be bi-cultural, which can be difficult. Although it can be helpful in some aspects such as education, it may cause confusion and rejection, because of the fear of leaving behind certain aspects of the Native American Indian culture (Atkinson, Morten, Sue, 1998; Weaver, 1999). Therefore, geographic contextual issues may take on heightened importance for counselors and researchers due to cultural incongruity.


A Call to Action


Gaps in the research related to Native American Indians as a population of multifaceted groups and individuals must be closed. Exploration of counseling issues related to Native American Indian by tribal affiliation and geographic living areas must be addressed to increase the multicultural knowledge and awareness of counselors. The counseling literature speaks to generic values that may or may not hold true for Native American Indians but might be encouraging counselors to think in a “one size fits all” perspective. As researchers and scholars we must begin to examine within group differences both by tribal affiliation and by geographic living conditions.


Native American Indians must be recruited as scholars and researchers within the counseling profession to add to the knowledge base and serve as role models in academe. This recruitment would provide role models and mentors for our native youth in both rural and urban areas, while keeping traditional values, culture and pride (Thomason, 1999).


In summary, Native Americans have a range of problems that may impact their help seeking behaviors. On a National level, the federal government has a responsibility of providing health care for Native Americans, which in turn has problems in funding, legislature, acceptance of responsibility, and trust. On a smaller level, helping professionals may be culturally incompetent, leading to a number of issues. On an individual level, ethnicity, tradition, and acculturation issues may negatively impact rural Native American communities. Research must be conducted with an open mind, free of primitive, romanticized bias thus exploring current, modern conditions of rural Native American Indians.




American Heart Association, (1997).  American Indian / Alaska Native and Cardiovascular Disease; Biostatistical Sheets. [on-line]. Available;


Atkinson D. R. , Morten G, & Sue D. W., (1998). American Indian Mental Health Policy. In T. LaFromboise (Ed.), Counseling American Minorities, (pp.137 – 158). United States: A Times Mirror Higher Education Group Inc., company.


Brucker P. S., & Perry B. J., (1998). American Indians: Presenting Concerns and Consideration for Family Therapists. The American Journal of Family Therapy, 26(4), 307-319.


Coleman, H. (1997). Conflict in multicultural counseling relationships: Source and resolution. Journal of Multicultural Counseling and Development, 25, 195-200.


Earle K. A., (1998).  Cultural Diversity and Mental Health: The Haudenosaunee of New York State.  Social Work Research, 22(2), p. 89-99.


Gates D. B., Howard-Pitney B., LaFromboise T., (1996). Help-Seeking Behavior of Native American Indian High School Students.  Professional Psychology: Research and Practice, 27(5), p 495-499.


Harris, B.J. (1987). Cultural Anthropology. (2nd ed.). New York: Harper Row.


Haviland, W.A.(1989). Anthropology. (5th ed.). Orlando, FL: Holt, Rinehart and Winston.


Herring, R., (1999).  Advocacy for Native American Indian and Alaska Native Clients and Counselees.  Advocacy in Counseling: Counselors, Clients, & Community. (p.33-40).  ERIC [accession No:ED435908].

Indian Health Service, (1997).  Trends in Indian Health 1997; General Mortality Statistics.  [on-line]. Retrieved 5, 12, 2003 from the worldwide web

LaFromboise T. D. (1993).  American Indian Mental Health Policy. In D. R. Atkinson, A. Morten, & D. W. Sue (Eds.), Counseling American Indian Minorities, (p.123-144). New York: Wiley.


Moran J. R., (1999). Measuring Ethnic Identity among American Indian Adolescents: A Factor Analytic Study.  Journal of Adolescent Research. 14(4), 405-426.


Nadler A., (1983). Personal Characteristics and Help Seeking.  In B. M. Depaulo, A. Nadler, & J. D. Fisher (Eds.). New Directions in Helping (p. 303-340).  New York : Academic Press.


Pfefferbaum R . L., Pfefferum B., Rhoades E . R., and Strickland R . J., (1998). Providing Health Care Needs of Native Americans: Policy, Programs, Procedures, and Practices. American Indian Law Review, 21(2), 211-258.


Richardson, B. (July 7,1993), New York Times, “More Power to the Tribes”, A15


Rothenberg, P. S., 4th edition, (1998).  Race Class and Gender in the United States.  St. Martins Press Inc. New York.


Thomason, T. C., (1999). Improving the Recruitment and Retention of American Indian Students in Psychology.  Northern Arizona University., American Indian Rehabilitation, Research, and Training Center.  Project Number D-9. (p. 1-16).  [ERIC accession NO:ED434790].


Weaver, H. N., (1999).  Assessing the Needs of Native American Communities: A North Eastern Example.  Evaluation and Program Planning. 22(2), 155-161.


Zimmerman, M.A., Ramirez-Valles, J., Washienko, K.M., Walter, B., & Dyer, S. (1996). The development of a measure of enculturation for Native American youth.  American Journal of Community Psychology, 24(2), 295-310.


Authors' Note:


Tarrell Awe Agahe Portman is an assistant professor at The University of Iowa and Dorieanna Dewey is a social worker in Reno, Nevada. Correspondence regarding this article should be sent by email to or telephone at 319-335-5985.