Cover Story

When it comes to health care, rural minority communities suffer from a double-whammy: They have many of the same concerns as urban communities, plus other problems--such as isolation and the absence of basic infrastructure--unique to rural areas. And of all rural minority groups, American Indians and Alaska Natives have perhaps been the hardest hit.

Suicide rates among young Indian men, for instance, are the highest of any demographic group in America, says Jamie Davis Hueston, PhD, a psychologist at the Indian Health Service (IHS). Many other behavioral health problems--from substance abuse and alcoholism to depression and anxiety--are widespread. And there is a severe shortage of American Indian psychologists and other mental health professionals available to meet those needs.

"We're really the most underrepresented minority group in psychology," says John Chaney, PhD, president of the Society of Indian Psychologists and director of the Indians into Psychology (INPSYCH) program at Oklahoma State University.

There are reasons to be hopeful, however. Despite the social breakdown that has taken place in many communities, extended families remain strong and cultural and linguistic traditions continue to provide a source of resiliency, says Hueston. And while the professional shortage remains serious, there are increasing numbers of doctoral-level American Indian psychologists and a new Div. 18 (Psychologists in Public Service) section to support them.

Unmet needs

Depressing statistics about mental health in American Indian communities are not hard to find: Unemployment rates of 70 percent and higher on some reservations, a poverty rate of almost 25 percent, a history of cultural oppression and insufficient funding for health care create stressful conditions that increase the likelihood of mental health problems.

Meanwhile, the total number of doctoral-level American Indian psychologists in the U.S. is estimated at less than 200, with a dozen or so new degrees granted each year--a tiny fraction of the number needed to serve the approximately 1.6 million American Indians and Alaska Natives eligible for health care from IHS.

Getting psychologists to work in Indian country can be hard, but retaining them is even harder, since even the most dedicated practitioners can find themselves drained after a few years.

"It's very, very difficult providing services to native people in rural communities," explains Candace Fleming, PhD, a psychologist at the University of Colorado who has worked with Indian communities in Washington, Montana and the Great Plains. "I would guess that one year in that setting is like two years in another setting," she says.

The INPSYCH program is one attempt to close the gap. Since the mid-1990s, it has been funding scholarships for doctoral candidates and outreach programs for college and high school students at the University of North Dakota (UND) and Oklahoma State University. A third program, at the University of Montana, has been funded since 2000.

Congress authorized INPSYCH in 1992 after a campaign led by APA and the office of Sen. Daniel K. Inouye (D-Hawaii), where former APA president Pat DeLeon, PhD, is chief of staff. Funding is currently provided through IHS's Scholarship Branch.

The program has already made a significant difference in the seven years since the first INPSYCH scholarships were awarded, says J. Doug McDonald, PhD, director of UND's INPSYCH program. UND alone has granted four doctorates and 16 master's degrees to American Indian students, he says, and all of its graduates now work for IHS or other Indian health providers.

Unfortunately, adequate funding for psychology training, as for other Indian health needs, remains elusive. Despite a recent advocacy effort by American Indian and Alaska Native psychologists in partnership with APA, total funding for INPSYCH has never topped the $1 million mark, says Nina Levitt, EdD, APA's director of education policy. "It's an extraordinarily worthwhile program, and it was heartbreaking to me that we weren't more successful," says Levitt.

One small victory came last year when Congress appropriated $50,000 to start a new program at the University of Alaska. But already-established programs have had to cope with small or nonexistent increases, despite rising costs. Graduate student stipends alone now take up more than half of Oklahoma State's $200,000 budget, says Chaney. That leaves very little for other critical programs, such as outreach to American Indian high school and college students.

Promising developments

Not all is gloom, however. Recently, Div. 18 established a new section called Psychologists in Indian Country, which now has more than 70 members. It should provide a much-needed networking and advocacy group for psychologists involved in American Indian and Alaska Native communities, says Hueston, the section's interim chair.

Positive developments are under way at IHS as well. With a budget of about $50 million for mental health and about $140 million for alcoholism and substance abuse treatment, IHS is limited in the services it can provide, so it has to choose carefully. IHS's new interim director, Charles W. Grim, DDS--the service's first nonphysician head--is focusing the service on prevention, recruitment and retention of health professionals, and improving understanding of health problems in Indian communities.

"This is a very exciting time at IHS, and it's an honor to be part of it," says Hueston.

For its part, APA continues to push for more mental health funding for Indian communities. The Public Policy Office, for instance, recently submitted language to federal appropriators that would provide funding for suicide prevention, says Senior Policy Analyst Denis Nissim-Sabat, PhD.

Finally, Indian communities themselves have been developing new ways of promoting health. For several decades, tribes have had the right to manage funds earmarked for Indian health care, and many of them are now providing services that were once provided by IHS.

Community education movements are also strong, with a growing number of health-focused powwows and other attempts--ranging from health-focused tribal radio programs to "wellness camp-outs"--to promote both traditional healing practices and mainstream psychology, says Fleming, who directs the training program at the University of Colorado's National Center for American Indian and Alaska Native Mental Health Research.

"There is a movement for recovery--not necessarily just recovery from alcoholism, although that's the common connection with the word 'recovery'--but recovery from the constant state of oppression over the years, recovery from the history of losses, recovery from contemporary challenges," says Fleming. "It's just wonderful to see recovery celebrated in a variety of ways."