Group Description
Native Americans have suffered immeasurably over the past five hundred years. After being defeated militarily by the U.S. government, they “experienced one of the most systematic and successful programs of ethnic cleansing the world has seen” (Whitbeck, Adams, Hoyt, & Chen, 2004, p. 121). Many were forced to move to “reservations,” which were essentially penal colonies with “no economic value to Europeans” (Whitbeck, Adams, Hoyt, & Chen, p. 121). Once there, they were forbidden to leave and had to rely on the U.S. government for their economic needs (Whitbeck, Adams, Hoyt, & Chen, p. 121). The government outlawed their indigenous religions and in many cases forced their children to attend American boarding schools with the intent of thoroughly acculturating them (Whitbeck, Adams, Hoyt, & Chen, p. 121).
This ethnic cleansing and acculturation continued for several generations (Whitbeck, Adams, Hoyt, & Chen, p. 121), and its affects remain evident among older Natives today. Many older Natives remain psychologically affected, having “either witnessed or heard the oral histories of genocidal assaults on their people and relentless attempts to destroy and exterminate their cultures” (Grandbois, Warne, & Eschiti, 2012, p. 4). Additionally, many of these individuals still live in the geographic regions which their forbears were moved; approximately one-fourth of older Natives live on reservations and more than half live in rural areas, mostly in the southwestern U.S. (Miller-Cribbs, Byers, & Moxley, 2009, p. 263).
Also largely because of this past oppression, Native Americans today—who currently makes up about two percent of the U.S. population (U.S. Department of Commerce, 2013)[1]—remain significantly poorer than the population at large. The average Native American household earns $35,310 annually, compared with $51,371 for all households (U.S. Department of Commerce, 2013). An astonishing 20 percent of Natives live in poverty, compared with 16 percent of the overall population (U.S. Department of Commerce, 2013). This number holds true for older Natives even though 11 percent of them work past the age of 65 (Miller-Cribbs, Byers, & Moxley, 2009, p. 266).
Largely because of the forced acculturation they encountered, many older Native Americans today “at least partially identify with Western worldviews and traditions” (Roman, Jervis, & Manson, 2011, p. 138). One study found that 41 percent of Natives over the age of 55 had “never participated in traditional activities and identified more strongly with mainstream culture” (Roman, Jervis, & Manson, 2011, p. 138). Nonetheless, many Natives have maintained or resurrected traditional Native cultures and in some cases have created “pan-Indian” cultures, fusing together common Native cultural elements (Roman, Jervis, & Manson, 2011, p. 138).
There are many different Native cultures, it should be noted. The U.S. government currently recognizes 562 tribes, each representing “different cultural groups with their own languages and practices and differences in historical experiences that influence relationships with those majorities of European descent” (Miller-Cribbs, Byers, & Moxley, 2009, p. 264). Some broad similarities between different tribal cultures exist, however. For example, tribal spiritual beliefs generally involve “faith in the interconnectedness of a higher being (e.g., the ‘Great Spirit’) and harmony with the natural world” (Roman, Jervis, & Manson, 2011, p. 138).
Most Native American cultures also share a “revered status of elders” (Roman, Jervis, & Manson, 2011, p. 138). Berthrong (1996) explains that in the past most tribes considered aging to be “a sign of favor by supernatural spirits that enable a person to acquire wisdom, knowledge of the world and its creatures, and tribal lore” (p. 179). Many tribes today continue to venerate older individuals, considering them “wise and connected to the spirit world” and valuing them as “the head of families and communities” to be “consulted for advice and guidance” (Roman, Jervis, & Manson, 2011, p. 138). Of course, it must be noted that in recent years the issue of elder abuse in Native communities has become increasingly prominent (Smyer & Clark, 2011).
Description of Life Stage and Needs
Older adulthood can be viewed as a struggle to maintain conditions—e.g., health, happiness, and financial stability—that often come easier earlier in life. Although health is not an automatic guarantee for people of any age, “[o]lder people are much more susceptible to physical illnesses than are younger people” (Zastrow and Kirst-Ashman, 2010, p. 611). Many who thought little about the consequences of their lifestyles while young must increasingly confront debilitating and sometimes life-threatening ailments later in life. The goal of this life stage can be seen as learning to make the changes in diet and lifestyle needed to sustain physical well being.
Older American Indians suffer a disproportionately high number of health problems. Goins and Pilkerton (2010) found that Native American aged 55 and older “experience higher rates of hypertension, diabetes, back pain, and vision loss compared to the general U.S. older adult population” (p. 350). Miller-Cribbs, Byers, and Moxley (2009) note that “[m]ajor health disparities also exist in tuberculosis, liver and kidney disease, smoking-related illness, pneumonia, and malnutrition” (p. 264). Goins, Moss, Buchwald, and Guralnik, (2007) found that American Indians aged 65 and older have a higher “prevalence of functional limitation, mobility disability, and self-care disability” than their white counterparts (p. 694). Not surprisingly, Native Americans are “less likely to rate their health as excellent or good as compared to other groups” (Miller-Cribbs, Byers, & Moxley, 2009, p. 264), and they live an average of eight years less than their white counterparts (Miller-Cribbs, Byers, & Moxley, p. 264).
Although people of all ages are susceptible to depression, depression is especially prevalent among older populations. Zastrow and Kirst-Ashman (2010) write that older people tend to be lonely, as most individuals over the age of 70 are single, often widowed or divorced (p. 619). Many older people, as Erik Erikson wrote, are plagued with despair generally not known when younger, feeling “regret about one’s past” and a “nagging desire to have done things differently” (Zastrow & Kirst-Ashman, p. 616). Ageism also contributes to depression among older people. As Zastrow and Kirst-Ashman write, “Our society does not allow many older people to experience their later years positively. We don’t respect their experience and wisdom, but instead dismiss their ideas as irrelevant and outdated” (p. 618). For these and other reasons, in the United States “the highest rates of suicide are found in the elderly” (Kennedy and Tanenbaum, 2000, p. 350). Erikson wrote that the goal in an individual’s final “psychological crisis” should be to attain “integrity,” which Zastrow and Kirst-Ashman describe as “an integration of one’s past history with one’s present circumstances, and a feeling of being content with the outcome” (Zastrow & Kirst-Ashman, p. 616).
Beals et al. (2005) found “[s]ignificant levels of comorbidity” between American Indians with “depressive and/or anxiety and substance disorders” (p. 99). Although the depression among older Native has not been studied extensively, one study found that over 30 percent of “Native elder outpatients at an urban IHS clinic were found to have significant depressive symptoms” (Roman, Jervis, & Manson, 2011, p. 129). It is possible that depression levels among older Natives might be higher than reported. Roman, Jervis, and Manson (2011) note that “efforts at cross-cultural translation of mental health terminology are problematic” and that “[s]ome tribal languages do not even possess a word equivalent to the English word ‘depressed’” (p. 135). Although “physical manifestations of psychiatric disorders may be recognizable across cultures, it is the idiomatic expression of such distress that complicates diagnosis and subsequently treatment” (p. 135).
Finally, although people of all ages can struggle with achieving or maintaining financial stability, this struggle is especially daunting for older individuals. Zastrow and Kirst-Ashman (2010) point out that very few older Americans have “substantial savings or investments” and that many “lack adequate food, essential clothes and drugs, and perhaps a telephone in the house to make emergency calls” (p. 646). Zastrow and Kirst-Ashman further note that these problems are compounded by high health care costs, which disproportionately affect older people, as well as inflation, which adversely affects those on fixed incomes (p. 646). The goal of this life stage can thus be described as continuing to provide for one’s own tangible needs with diminished means.
As described in the previous section, Native Americans in general, and older Natives in particular, face more severe economic challenges than the population at large.
Interventions
Micro-Interventions
In recent years, a growing number of Western therapists have begun seeking ways to “tailor conventional psychotherapies for the benefit of peoples immersed in beliefs, practices, and worldviews that diverge substantially from those of the Western middle classes” (Gone, 2009, p. 168). Some of these therapists have “incorporated [Native] spirituality in counseling sessions and have achieved a modicum of success” (Trimble, 2010, p. 248). Simms (1999), for example, counseled a 27-year-old Native woman with “identity confusion and a lack of self-confidence” (p. 21). Simms gave this woman traditional cognitive-behavioral therapy combined with different Native healing methods, which involved participation in “the talking circle and sweats, cultural forums for attending to spiritual needs” (p. 21). Through this hybrid approach, Simms enabled her client to find the support she needed to eventually “make healthier choices about her drinking” (p. 21).
Although the logic behind this kind of integrative approach makes sense, few studies have been published on such methods (Trimble, 2010, p. 248). To date there is very little evidence, certainly no quantitative evidence, showing that these approaches work. It must also be pointed out that no studies exist showing that such methods work well with older Native Americans.
Mezzo-Interventions
LaFromboise, Trimble, and Mohatt (1990) write that it is doubtful that a one-on-one, client-therapist relationship, “outside the context of family and community, is a valid and/or pragmatic means of dealing with an Indian client’s problems” (p. 639). Many Native Americans, they note, “have been raised in a culture that has historically relied on group consensus to prevent and deal with community and tribal problems” (p. 642). Consequently, LaFromboise, Trimble, and Mohatt advocate network therapy, which “operates on a model similar to and consistent with the more traditional Indian community-oriented guidance system” (pp. 641-642). In network therapy, “a clan or group of family, relatives, and friends is organized and mobilized to form a social force or network” (p. 642). The counselor is merely the “catalyst,” there to help “conduct the process,” while it is “the social support system which works to deal with the crisis or bring the person out of isolation” (p. 642).
Just as with the above-mentioned hybrid micro-intervention, few studies have been conducted on network therapy. LaFromboise, Trimble, and Mohatt (1990) cite one study which they claim shows that network therapy is “a viable, culturally consistent approach for preventing and dealing with psychiatric problems in Indian communities” (p. 642), but this study was not even conducted in a Native American community, let alone among older Native Americans, and it merely showed that those who were given network therapy were subsequently less likely to utilize various mental health services than those who were not given network therapy (Schoenfeld, Halevy-Martini, Hemley-Van der Velden, & Ruhf, 1985, p. 281), an outcome that can be interpreted in different ways.
Macro-Interventions
In 1997 the U.S. Congress established the Special Diabetes Program for Indians (SDPI) to counter the epidemic of diabetes in the Native American community (Indian Health Service, 2011, p. 9). With an annual budget of $150 million (National Indian Health Board, 2014), the program “provides grants for diabetes treatment and prevention services to 404 HIS, Tribal, and Urban Indian health programs across the Indian health system” (Indian Health Service, 2011, p. 9).
SDPI’s Diabetes Prevention Program offers “group classes and individual coaching sessions” (Indian Health Service, 2011, p. 11) that encourage “weight loss, diet change, and increased physical activity” among adults “at high risk of developing type 2 diabetes” (Knowler and Ackerman, 2013, p. 1820). Researchers recently showed that this intervention reduced the diabetes incidence rate by 58 percent (Knowler and Ackerman, 2013, p. 1820).
SDPI’s Healthy Heart Project employs “intensive case management, including medical care and patient education strategies” to reduce behaviors that elevate one’s risk of getting cardiovascular disease (Indian Health Service, 2011, p. 11). A recent trial found that over a three-year period the program’s participants “made improvements in key cardiovascular risk reduction behaviors” (Indian Health Service, 2011, p. 11). Specifically, the number of participants who engaged in the following behaviors increased: not smoking, from 79 percent to 89 percent; eating healthy foods at least once a week, 78 percent to 86 percent; eating unhealthy foods less than once a week, 68 percent to 81 percent; exercising at least 150 minutes a week, 27 percent to 40 percent (Indian Health Service, 2011, p. 12).
A second macro-intervention worth looking at is Services for Native Americans, which is outlined Sections 613, 623, and 631 of the Older Americans Act. Services for Native Americans provides grants to different tribal organizations in an attempt to ease the financial burdens of older Natives. Services for Native Americans gave a total of $38 million in grants in fiscal year 2011, which provided the following services, among others: “approximately 894,376 rides to meal sites, medical appointments, pharmacies, grocery stores, and other critical daily activity locations,” “more than 2.4 million meals to over 20,000 homebound Native American elders,” “over 2.0 million meals to nearly 50,000 Native American elders in community-based settings,” and “nearly 1.2 million units” of in-home services to Native elders (U.S. Department of Health and Human Services, n.d.). Although the argument can certainly be made—although perhaps not persuasively—that this money could be better spent elsewhere, the above numbers speak for themselves, and it is indisputable that Services for Native Americans provides tangible relief to a very destitute community.
Advocacy
As should be clear by now, older Native Americans are not receiving the help they need. The Special Diabetes Program for Indians has proven to be especially effective at altering behaviors which can cause diabetes and cardiovascular disease, but the program is not adjusted for inflation; consequently its funding, in real terms, has been declining every year since 2002. The National Indian Health Board (2014) notes that, “[c]alculating for inflation, [SDPI’s budget of] $150 million in 2002 would be about $115 in 2014—or 23 percent less.” Similarly, the Older Americans Act has not kept pace with inflation for the past several years, and, given the current political environment, it seems unlikely that it will receive a funding increase in the foreseeable future (Sanders et al., 2014).
Although the above mentioned micro- and mezzo-interventions seem promising—based on theoretical grounds and a limited number of case studies—additional research is needed to confirm this. Such research will also require more funding, as well as time. And if these interventions can be shown to be effective, then even more money will be needed to promote them and to teach them to therapists and social workers. Again, due to the currently political environment, it will likely be difficult to raise this money anytime soon.
The need to provide this additional help to older Native Americans can be justified on Rawlsian grounds. John Rawls (1999) believed that humans are rational, self-interested beings who consequently favor principles of justice that favor themselves. The wealthy, for example, “advance the principle that various taxes for welfare measures be counted unjust,” while the poor “propose the contrary principle” (p. 17). Because of this, Rawls argued that the best way to choose principles of justice is to pick them behind a “veil of ignorance.” In other words, he imagined a “hypothetical situation” in which “no one knows his place in society, his class position or social status, nor does any one know his fortune in the distribution of natural assets and abilities, his intelligence, strength, and the like” (p. 11). Rawls believed that people behind the veil would conclude that, although “the distribution of wealth and income need not be equal, it must be to everyone’s advantage” (p. 53).
Based on this principle, it follows that a just society would do more to provide for the Native American community. In other words, if one could not pick their place in society and therefore had the chance of being born as a member of this non-dominant group, they would choose a society that distributed its social goods in a way that provided more help to Native Americans.
More funding for the above interventions is an important first step, but, given the many severe challenges facing older Native Americans, that does not go far enough. New and creative approaches are also needed. Hodge and Nancy (2011) found that Native Americans tend to associate “cultural connectivity” —defined as “the ability to speak tribal languages, participating in American Indian practices, and feeling connected to the community”—with their “perceptions of wellness” (p. 800). From this they concluded that “maintaining cultural connectivity is healthy for individuals” and that its loss “can be measured and studied in association with other risky behaviors, such as alcohol and drug abuse, obesity, and psycho-social problems, as well as poor health conditions” (p. 800). Consequently, they advocate “a culturally-sensitive intervention” involving “the Talking Tree, a culturally-appropriate group support method and educational forum” which they claim will “reduce obesity, improve good health habits, and improve perceptions of wellness” (p. 800). But again, although this, and conceivably other proposed interventions, sound promising, resources are needed to test them and, if they are shown to be effective, to implement them.
Conclusion
Many great and creative minds have studied the older Native American population and conceived interventions to improve their lives. The next hurdle for those in the helping professions is not to come up with more ideas but to persuade others to better fund the current interventions. The current challenge of social workers, then, is to educate the public, to impart the plight facing older Native Americans and the many proven and many promising means of helping them. Although there is a strong and perhaps rising current of Randian libertarianism in this country—emphasizing the virtues of self-sufficiency and decrying any proposal to help those in need—social workers can strive to popularize the arguments of John Rawls and other advocates of social justice. By appealing to the public’s sense of compassion and fairness—for fairness can be an ally of liberalism, not just libertarianism (Haidt, 2013)—social workers can persuade many minds and in the process help those most in need.
References
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Berthrong, D.J. (1996). Elders. In Encyclopedia of North American Indians (Houghton Miffin) (pp. 179-181). U.S.: Houghton Miffin Harcourt Publishing Company.
Goins, R.T., Moss, M., Buchwald, D., and Guralnik, J.M. (2007). Disability among older American Indians and Alaska Natives: An analysis of the 2000 census public use microdata sample. The Gerontologist, 47(5), 690-696.
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[1] Because the US Census Bureau does not distinguish between American Indians and Alaska Natives, these the two groups will be treated as one entity in this section.
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