Moving from colonization toward balance and harmony: a Native American perspective on wellness.

Hodge, David R. ; Limb, Gordon E. ; Cross, Terry L. 等

Current mental health practices appear to be largely ineffective in terms of meeting the needs of many Native Americans (Graham, 2002; Weaver, 2004). According to nationally representative survey data (N = 134,875), Native Americans are significantly more likely to indicate that they have unmet needs in the area of mental health care than are white Americans (Harris, Edlund, & Larson, 2005). Conversely, the perceptions of unmet mental health care needs among African Americans, Asians, and Hispanics are usually lower than those of white Americans--often significantly lower (Harris et al., 2005). The high level of unmet needs among Native Americans calls for some type of explanation.

In what might be considered the conventional hypothesis, the higher perceived need among Native Americans is related to the existence of higher rates of mental health challenges in this population. Indeed, a substantial body of research indicates that the prevalence rate of mental health challenges among Native Americans is significantly higher than it is among white Americans and many other populations (Beals et al., 2005; Harris et al., 2005; Kulis, Napoli, & Marsiglia, 2002; Stiffman et al., 2006; Weaver, 2004). Thus, perceptions of unmet need are posited to exist because of the magnitude of the challenges and the scarcity of resources. The solution, according to this view, is to increase access to professional service providers so that mental health challenges can be met.

This hypothesis, however, is based on the premise that Native Americans lack sufficient access to professional service providers. Yet according to recent, nationally representative data, Native Americans are just as likely as whites Americans to use mental health services (Harris et al., 2005). This is true for those experiencing one or more health symptoms as well as for those with serious mental illness. For instance, among Native Americans with serious mental illness (n = 161), roughly 61 percent had used mental health services (Harris et al., 2005). In absolute terms, this was the highest percentage of service usage among the groups surveyed. These data suggest that the high level of perceived unmet mental health needs cannot be attributed solely to lack of access to mental health services.

An alternative, critical viewpoint posits that the problem lies not with the degree of access but with the services themselves. Professional mental health services are often perceived by Native Americans to be ineffective (Graham, 2002; Weaver, 2004). One recent survey of tribal members living on four reservations (N = 965) assessed the effectiveness of various types of services commonly used to address mental health and substance abuse problems (Walls, Johnson, Whitbeck, & Hoyt, 2006). Of the 21 types of services assessed, those provided by professional service providers were perceived to be the least effective. Services provided by off-reservation social workers, the most numerous providers of mental health services in the United States, were perceived to be the least effective of all.

In short, perhaps the reason so many Native Americans report unmet mental health needs--despite receiving relatively high levels of mental health services--is simply because the provided services do not meet their needs. The service models are simply ineffective. Yet, as implied earlier, much of the existing scholarship on Native Americans supports, either implicitly or explicitly, existing Western models of service delivery.

This article provides an alternative viewpoint, positing that the Western therapeutic project is inconsistent with many Native American cultures and often serves as a form of Western colonization. We suggest abandoning this value-informed project and rebuilding the helping process on tribal knowledge foundations. In keeping with this goal, we offer a relationally based Native perspective in which wellness results from the complex interplay of spirituality, physical status, cognitive and emotional processes, and environment. Before proceeding, however, the diversity of perspectives that exists among Native Americans should be noted.

NATIVE AMERICAN--A CONSTRUCTED CONCEPT

It is important to recognize that terms such as "Native American" and "American Indian" are linguistic devices designed to denote contemporary descendents of a wide variety of tribal nations. Over 550 American Indian tribes are currently recognized by the federal government (Fuller-Thomson & Minkler, 2005). In addition, many other tribes are recognized only by state governments, and still others are working to obtain official governmental recognition. Each tribe, whether recognized or not, is informed by a culturally unique worldview (Trujillo, 2000; Whitbeck, 2006).

Although Native Americans commonly affirm a number of values (Cross, 1997; Jackson & Turner, 2004), no single Native perspective exists among the 4.3 million people who self-identify as American Indian or Alaskan Native in the United States (U.S. Census Bureau, 2000). In this article, we present one Native perspective that has broad resonance among many Native Americans. Before delineating this perspective, we discuss how mainstream mental health services can oppress Native clients, in spite of good intentions on the part of practitioners.

THERAPY AS COLONIZATION

In practice settings, it is widely accepted that the theoretical perspective brought to the table influences how problems are conceptualized and addressed (Tjeltveit, 1999). Practitioners using a cognitive perspective may be more likely to view problems as stemming from unhealthy schemas and recommend interventions that emphasize salutary thoughts. Alternatively, those operating from a behavioral theoretical framework may be inclined to believe that altering patterns of behavior is the best way to help clients ameliorate problems.

Although it is commonly accepted that values inform direct practice, less thought is typically given to the values that animate the larger, Western therapeutic project (Coates, Gray, & Hetherington, 2006). Debate exists about the efficiency of various therapeutic modalities (Chambless & Ollendick, 2001; Hepworth, Rooney, Rooney, Strom-Gottfried, & Larsen, 2006), but the effectiveness of the larger therapeutic enterprise is typically assumed. Therapy is viewed as the appropriate means to address mental health needs across cultures and populations. Put differently, psychotherapy is implicitly understood to be a neutral, scientifically based vehicle through which mental health problems are best ameliorated.

All human constructions, however, are informed by certain sets of values. The therapeutic project is informed by and reflects the values of the Western Enlightenment worldview from which it emanated (Cross, 1997, 1998; Gray, 2008; Jafari, 1993; Red Horse, 1997; Voss, Douville, & Little Soldier, 1999). It is important to note that not all westerners accept the premises of the Enlightenment, which have come under considerable criticism from some members of the dominant secular culture (Lyotard, 1979/1984). Nevertheless, Enlightenment values continue to guide the trajectory of the therapeutic project.

To be clear, we are not talking about individual practice modalities but therapy as a larger enterprise. This project entails numerous assumptions about the nature of reality. Included among these are the assumption that "good mental health" is an end worth pursuing; various assumptions about what constitutes both good mental health and dysfunction; and assumptions that the discussion and exploration of problems benefits those who suffer, problems can be isolated and interventions targeted to the localized problem, outcomes in a specific area can be monitored and measured, and secular licensed professionals are best suited to guide people through the heating process.

Because some degree of consensus exists regarding these assumptions among mental health professionals, the underlying values are rarely questioned. To service providers who have been socialized to accept them, the prevailing norms seem correct, true, and appropriate. Although it is recognized that various therapeutic modalities shape practitioners' understandings, the values that inform the larger professional framework are unconsciously accepted. After years of professional training, the professional mental health paradigm is implicitly assumed to reflect the world as it is rather than one particular understanding of reality (Gone, 2004; Kuhn, 1970).

The suppositions that inform many Native worldviews differ from the Enlightenment worldview that serves as the foundation on which the Western counseling project is constructed (Frame, 2003; Miller, 2003; Trujillo, 2000). At a foundational, suppositional level, a clash in values exists in many areas. Native understandings of wellness are typically not entertained as legitimate options within the Western therapeutic project. The array of options presented to Native clients fails to resonate with them because such options tend to fall outside the parameters of Native worldviews. Consequently, many Native clients experience therapy as oppressive, because their worldviews are effectively marginalized by mainstream mental health theory and practice (Coates et al., 2006).

Native clients are subtly encouraged to adopt a culturally foreign worldview through their engagement in the counseling process (Gone, 2004). In essence, therapy functions as an agent of colonization (Coates et al., 2006).The only options on the table, the only options deemed legitimate within the therapeutic project, are foreign ones. Because practitioners sincerely believe in the worth of the larger project, they encourage Native clients to engage the options sanctioned by the therapeutic project. Thus, despite good intentions on the part of practitioners, culturally different Native clients are subtly coerced into adopting norms derived from a Western, Enlightenment worldview (Yellow Bird, 2004).

To be clear, adapting therapy with multicultural techniques--for example, matching clients on the basis of gender, factoring in level of acculturation, or tailoring communication style to match that of the client--in and of itself, does little to mitigate the colonization (Gone, 2004). Such techniques function to repackage the counseling project in more palatable dress while leaving its central colonizing function intact. The fact must be faced that professional therapy is a thoroughly enculturated project. As such, it is time to consider revaluating or even abandoning this project and rebuilding the helping process on an indigenous knowledge foundation (Walls et al., 2006). We discuss the parameters of such a Native perspective on helping in the following section.

Before proceeding, it is important to note that space constraints preclude discussion of all of the issues raised in the foregoing discussion. Take, for instance, the issue of what constitutes good mental health. Characteristics viewed as markers of psychopathology in the dominant secular culture may be understood as indicators of well-being in many Native American settings (Cross, 2001). For example, communicating with the Creator or other metaphysical dimensions of the spiritual world can signify health and well-being in many Native tribes. Conversely, in the context of the dominant culture, such events are often construed as indicators of psychopathology, with hearing a voice external to one's self commonly understood to be a marker of schizophrenia (American Psychiatric Association, 2000).

Although we acknowledge the importance of such issues, we limit the present discussion to a Native perspective on wellness, drawn primarily from the work of Cross (1997, 1998, 2001), supplemented by those influenced by his work (Coates et al., 2006; Graham, 2002; Limb & Hodge, 2008) and other Native American scholars. Central to this relationally based perspective are the interrelated concepts of spirit, body, mind, and context.

A NATIVE MODEL OF WELLNESS

Spirit, Body, Mind and Context

In the Native model, in contrast to the dominant secular culture, spirituality is perceived to be central to wellness (Gilgun, 2002; Lowery, 1998). At the core of one's existence is the spiritual (see Figure 1).We are not so much humans on a spiritual journey as spirits on a human journey--a journey in which our spirits will continue to exist in the hereafter (Cross, 2001).

[FIGURE 1 OMITTED]

In addition to the human spirit, spirituality also includes transcendent dimensions (Gesino, 2001; Weaver, 2005). People are in relationship with the Creator and with what might be called positive and negative spiritual forces. These forces are labeled differently by various traditions. Examples of negative forces are signified by such terms as "bad luck," "evil spirits," "ghosts," and "the devil" (Cross, 1997). Although typically unseen, these forces are real and influence people for both good and bad in this material dimension of existence.

During their human journey, people exist in a physical body. As is the case with our spirits, many factors also affect our physical condition (Graham, 2002). Included among these are genetics, age, nutrition, sleep, physical fitness, and substance use (Cross, 1998). Although some characteristics, such as genetic makeup, are more difficult (if not impossible) to change, others, such as nutrition or physical fitness, can be changed with relative ease.

Interconnected with both the spirit and the body is the mind (Coates et al., 2006). It is important to emphasize that "mind" in this context represents a broader understanding than is typical among western mental health professionals (Graham, 2002). In addition to purely cognitive components like memory, it also includes intellect, judgment, experience, and affect (Cross, 1997). As such, the concept includes the notion of personality but goes beyond it.

People are not isolated beings but, rather, exist in a particular context. Included in this context are climate, work, family, community, culture, and history (Cross, 1997).As part of their journey, people are born into a particular family that exists in a community that has a unique culture and history. In turn, this context or environment shapes people in various ways (Weaver & Brave Hart, 1999). For instance, trauma, unemployment, and crime typically have a negative impact, whereas Native traditions, family members, and tribal elders often have a positive influence.

With this being said, it is also important not to romanticize Native cultures, as some members of the dominant culture have done (Weaver, 2005). As is the case with all cultures, Native cultures have strengths and weakness. Although belief in a transcendent spiritual reality is often an asset, it can also be a limitation. For example, some Native clients can understand the notion of bad luck in a deterministic manner that functions to unduly limit choices that would be legitimate within a given tribal context. Balance is central to evaluating cultures and to promoting wellness.

Balance as the Key to Wellness

As implied in the previous section, spirit, body, mind, and context are interconnected (Coates et al., 2006; Gilgun, 2002). Consequently, change in one area influences other areas (Lowery, 1998). For example, the sudden onset of unemployment may produce a sense of sadness and anxiety, which is augmented by bad spirits. In turn, this state may result in a loss of appetite and sleep, further exacerbating an already precarious mental state. Although some Western perspectives would see a linear connection between unemployment, sadness and anxiety, and loss of appetite and sleep, within a Native context these events are conceptualized in a more circular, spherical manner in which each event is viewed in relationship to the others.

Health and well-being are the result of the complex interplay among our spirituality, physical status, cognitive and emotional processes, and environments (Cross, 2001).When all four areas are in balance, we are said to be healthy. This relationship is depicted in Figure 2. As can be seen in the figure, each area has equal weight. Wellness occurs when each area is functioning in harmony with the other areas. Although balance and harmony are related, intertwined constructs, they can be distinguished (Cross, 2007).

[FIGURE 2 OMITTED]

Balance is a natural state that results from the normal processes of stimuli and response, drive and drive satisfaction, and complex system interactions. Some degree of balance occurs naturally among the areas depicted in Figure 2, with or without intervention. Without intervention, balance may be functional but not necessarily optimal. For example, children in an alcoholic family may develop coping strategies that maintain some form of balance in their given situation but also leave them vulnerable. As long as humans survive, some form of balance exists naturally.

Harmony, conversely, requires effort. Harmony results from the active pursuit of more optimal or positive balance. This process entails the use of self-discipline and some forms of cultural, spiritual, or mental practices or therapeutic interventions, such as those depicted in Figure 2 (for example, ceremonies, memorials). Ideally, the process creates a condition in which each of the quadrants generates positive energy. The energy of the whole system then becomes greater than the sum of its parts. When in harmony, people thrive, are resilient beyond expectation, and contributes in a synergistic manner to those around them with their energy.

A number of practice implications flow from this understanding of wellness. As stated earlier, people are usually able to maintain some form of balance and, thus, are able to function in a generally healthy manner. Health and wellness, however, are not always preserved as people move through life. In such cases, some Native American clients will encounter mental health professionals (Gone, 2004; Limb & Hodge, 2008).

IMPLICATIONS FOR MENTAL HEALTH PROFESSIONALS

Mental health professionals are typically trained to isolate problem areas in human functioning, for which interventions are then developed. The problem is commonly thought to exist with or within the person in some sense. A practitioner working from a cognitive perspective, for instance, attempts to correct a client's unproductive thought patterns (Ellis, 2001). The problem, from this perspective, is with the client, specifically her or his schema. Viewing the problem as residing with the person can foster a milieu in which the person becomes completely identified with the problem, as occurs when people are called "schizophrenics" (Hodge, 2004).

The Native perspective discussed in this article calls for a completely different way of addressing problems. Rather than treating the person, the healer treats the balance (Cross, 1997).The problem lies not within the person but in the lack of balance and harmony among spirit, body, mind, and context. Adjusting the balance among these four areas restores wellness.

Healers focus on understanding challenges through the complex relationships among spirit, body, mind, and context. Rather than using a linear cause-and-effect framework, healers approach challenges using a relational, intuitive framework in which all variables are understood to be interconnected (Graham, 2002). Because of the interrelationship among variables, changing one area results in changes throughout the larger system.

Four sample interventions in each of the four areas are listed in Figure 2. It should be noted that these interventions are illustrative and may not be relevant to all Native Americans. Although the concepts of spirit, body, mind, and context are likely to hold broad resonance across tribes, interventions designed to promote balance and harmony will vary considerably from tribe to tribe and person to person.

With these cautions in mind, these sample interventions are relatively representative of the types of practices that might be used to foster wellness. In some cases, the nature of the intervention is readily apparent. A case in point would be a client needing better nutrition, extra sleep, more exercise, additional recreation, or some other type of intervention designed to restore harmony in the realm of the body.

In the areas of mind and context, the interventions may be more unfamiliar. Storytelling, reminiscing, remembering, and memorializing are traditional, mind-oriented interventions that can engender wellness by selectively emphasizing certain experiences, values, and feelings. For instance, reminiscing about past events in which problems were successfully overcome can help bring harmony to the mind by instilling hope that present difficulties can be overcome.

As noted, the person exists in a given context, which typically includes family, elders, culture, and traditions. Each environmental factor can be understood and operationalized as an intervention. Health can often be enhanced, for instance, by restoring family unity, consulting the wisdom of elders, or reconnecting individuals with their culture or traditions.

Although not listed as such, it should also be noted that more traditional therapeutic interventions might also be used in the areas of mind and context. A cognitive intervention, for example, might be used to address unproductive thought patterns. In some cases, a traditional therapeutic perspective might be used in conjunction with one of the more traditional tribal interventions to enhance its effectiveness. For instance, operating from a systems perspective, a structural intervention might be used with a family.

Given the intertwined nature of many of these interventions, they are often best conducted with other tribal members. For example, clan members can often facilitate the process of storytelling, increasing the significance of the exercise. Likewise, reminiscing with tribal elders may help clients to reconnect with their traditions while enhancing their resilience. Incorporation of tribal members into the process is particularly important in the area of spirituality.

Perhaps the most complex set of interventions occurs under the rubric of the spirit. Spiritual interventions are often intensely private affairs (Trujillo, 2000). Many tribal ceremonies and rituals are not open to outsiders. Similarly, the sharing of dreams or prayers is often proscribed outside of tribal circles. Although this area is of foundational importance, any discussion of spiritual matters must proceed tentatively and with the utmost caution because of the sacred nature of many Native spiritual practices.

As implied in the foregoing, spiritual, psychological, contextual, or physical interventions might be used to promote balance and harmony. Because restoring balance is the crucial issue, it is important to emphasize that interventions are not necessarily aimed at specific problem areas. Rather, healers attempt to understand the interplay among interdependent systems, and they design interventions accordingly.

This understanding of healing differs dramatically from that held within the Western therapeutic project. For instance, using the linear, cause-and-effect framework of mainstream mental health, a problem such as chemical dependency is typically addressed by developing psychological interventions that address the mind (Blazer, 2003; Ellis, 2001; Longabaugh et al., 2005). As we have noted, the use of such interventions is not necessary proscribed from a Native perspective. In some cases, a cognitive intervention may be appropriate. The problem is not with the intervention in and of itself but with the larger linear, cause-and-effect framework.

In contrast, Native perspectives typically affirm a more circular, holistic approach. Addictions, for example, may be the product of an unbalanced relationship with the Creator. In such situations, a cognitive intervention that addresses the mind is unlikely to be effective. Rather, the best way to address substance abuse may be a spiritual intervention that restores harmony between the individual and the Creator. A renewed spiritual connection with the Creator, manifested in the form of a dream, may play a critical role in recovery from chemical dependency (Lowery, 1998). Once balance is restored, the problem is ameliorated.

The interconnected nature of problems is often difficult for mainstream mental health professionals to understand because of years of socialization that have privileged Western scientific knowledge claims over spiritual knowledge. As Cross (2001) observed, the Western therapeutic project has often pathologized religious beliefs and categorized spiritual phenomena as dysfunctional. Indeed, woven into the Enlightenment worldview at a basic, presuppositional level is an antireligious bias (Gellner, 1992; Gray, 2008).

Yet for many Native Americans, spirituality is critical to wellness and healing (Gone, 2004; Stone, Whitbeck, Chen, & Johnson, 2005). For instance, in one chemical dependency project, many Native women linked their decision to stop using substances to a spiritual experience, such as a dream, a vision, or a transcendent voice encouraging them to stop using (Lowery, 1998). Restoring harmony with the spiritual realm played an instrumental role in recovery (Lowery, 1998; Stone et al., 2005).

Implementing a Native perspective in mental health settings will typically require a collaborative effort. Social workers are required by the NASW Code of Ethics (NASW, 2000) to remain within their areas of professional competency. Given their socialization into the Western therapeutic project, they are unlikely to have the knowledge, skills, or training to work with Native clients in the manner delineated in this article.

Consequently, it will usually be necessary to form working relationships with specialists in Native spirituality and culture. As mentioned earlier, each tribe has a distinct worldview, and, consequently, collaborations should reflect this reality (Whitbeck, 2006). Although the basic concepts presented in this article are widely affirmed among Native Americans, they are operationalized in various ways. For instance, spirituality may be expressed within contexts as varied as Catholicism, indigenous settings, Pentecostalism, the Native American Church, or some combination of these (Gone, 2004).Thus, collaboration may entail working with medicine men, pastors, elders, priests, teachers, or other individuals with specialized knowledge.

To identify individuals with whom to collaborate, practitioners should consult their clients (Weaver, 2003). Given the diversity of potential collaborators, social workers must be careful not to favor certain types of associations that are based on their predetermined notions of what constitutes an appropriate collaborator. As experts on their own life circumstances, clients are ideally situated to suggest the most appropriate collaborator to meet their needs.

Before such conversations can occur, however, it is usually necessary to spend some time establishing trust (Jackson & Turner, 2004; Weaver, 2003). Initially, clients may assume that non-Native practitioners buy into the assumptions of the Western therapeutic project. Hesitancy is to be expected in such situations. Consequently, it may take some time to develop sufficient rapport to ensure that clients feel comfortable exploring alternative methods of addressing problems.

CONCLUSION

Social work is a profession ethically committed to providing effective services (NASW, 2000).Yet, despite good intentions, the services provided by mental health professionals have failed to adequately address the needs of Native Americans (Harris et al., 2005). As currently constructed, the Western counseling project delivers services that are often ineffective and function as a vehicle for colonization (Coates et al., 2006; Gone, 2004; Walls et al., 2006).

In light of this situation, it is time to consider transforming service provision, rebuilding it upon Native understandings of reality (Whitbeck, 2006). Instead of dressing secular Western frameworks up in culturally competent garb, it is time to construct Native practice modalities from the ground up. New helping models--built on a Native presuppositional foundation rather than an Enlightenment presuppositional foundation--must be constructed.

Fortunately, openness to such innovations may be growing. As implied earlier, the philosophical cracks in the Enlightenment foundation on which the Western counseling project rests are increasingly recognized across cultures (Ermarth, 1998; Lyotard, 1979/1984). Professional interest in spirituality and nonmaterial understandings of reality is growing (Cnaan, Boddie, & Danzig, 2005; Hodge, 2006). A new era in which diverse worldviews are regarded as being on a par with the dominant secular worldview may be emerging.

Toward this end, we have sketched out one Native practice perspective in this article. Other perspectives representing different Native understandings, however, are needed. As noted earlier, no single Native perspective exists (Trujillo, 2000; Whitbeck, 2006). Different tribes, operating from different presuppositional foundations, will construct different helping models. It is our hope that future professional discourse will expand its understanding of diversity sufficiently to include such models.

Original manuscript received April 30, 2007

Final revision received December 18, 2008

Accepted February 3, 2009

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beals, J., Novins, D. K., Whitesell, N. R., Spicer, P., Mitchell, C. M., & Manson, S. M. (2005). Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: Mental health disparities in a national context. American Journal of Psychiatry, 162, 1723-1732.

Blazer, D. G. (2003). Depression in late life: Review and commentary. Journal of Gerontology: Medical Sciences, 58A, 249-265.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.

Cnaan, R.A., Boddie, S. C., & Danzig, R.A. (2005). Teaching about organized religion in social work: Lessons and challenges. Journal of Religion and Spirituality in Social Work, 24(1/2), 93-110.

Coates, J., Gray, M., & Hetherington, T. (2006).An "ecospiritual" perspective: Finally, a place for indigenous approaches. British Journal of Social Work, 36, 381-399.

Cross, T. (1997). Understanding the relational worldview in Indian families [Part 1]. Pathways Practice Digest, 12(4). Retrieved April, 4, 2007, from http://www.nicwa. org/services/techassist/worldview/worldview.htm

Cross, T. (1998). Understanding family resiliency from a relational world view. In H. McCubbin, E. Thompson, A. Thompson, & J. Fromer (Eds.), Resiliency in Native American and immigrant families (pp. 143-157). Thousand Oaks, CA: Sage Publications.

Cross, T. (2001). Spirituality and mental health: A Native American perspective. Focal Point, 15(2), 37-38.

Cross, T. L. (2007, June 25). Cultural competency: American Indians and the history of child welfare. Paper presented to the National Indian Child Welfare Association Council on Accreditation, New York.

Ellis, A. (2001). Overcoming destructive beliefs, feelings, and behaviors: New directions for rational emotive behavior therapy. Amherst, NY: Prometheus Books.

Ermarth, E. D. (1998). Postmodernism. In E. Craig (Ed.), Routledge encyclopedia of philosophy (Vol. 7, pp. 587-590). New York: Routledge.

Frame, M.W. (2003). Integrating religion and spirituality into counseling. Pacific Grove, CA: Brooks/Cole.

Fuller-Thomson, E., & Minkler, M. (2005). American Indian/Alaskan Native grandparents raising grandchildren: Findings from the Census 2000 Supplementary Survey. Social Work, 50, 131-139.

Gellner, E. (1992). Postmodernism, reason and religion. New York: Routledge.

Gesino, J. P. (2001). Native Americans: Oppression and social work practice. In G.A. Appleby, E. Colon, & J. Hamilton (Eds.), Diversity, oppression, and social functioning (pp. 109-130). Needham Heights, MA: Allyn & Bacon.

Gilgun, J. F. (2002). Completing the circle: American Indian medicine wheels and the promotion of resilience of children and youth in care. Journal of Human Behavior in the Social Environment, 6(2), 65-84.

Gone, J. P. (2004). Mental health services for Native Americans in the 21st century United States. Professional Psychology: Research and Practice, 35, 10-18.

Graham, T.L.C. (2002). Using reasons for living to connect to American Indian healing traditions. Journal of Sociology and Social Welfare, 29, 55-75.

Gray, M. (2008).Viewing spirituality in social work through the lens of contemporary social theory. British Journal of Social Work, 38, 175-196.

Harris, K. M., Edlund, M. J., & Larson, S. (2005). Racial and ethnic differences in the mental health problems and use of mental health care. Medical Care, 43, 775-784.

Hepworth, D. H., Rooney, R. H., Rooney, G. D., Strom-Gottfried, K., & Larsen, J. A. (2006). Direct social work practice: Theory and skills (7th ed.). Belmont, CA: Brooks/Cole.

Hodge, D. R. (2004). Spirituality and people with mental illness: Developing spiritual competency in assessment and intervention. Families in Society, 85, 36-44.

Hodge, D. R. (2006). Editorial: Spirituality and religion in social work turn 50: Taking stock of what's been accomplished and surveying the landscape ahead. Arete, 30(1), 3-7.

Jackson, A., & Turner, S. (2004). Counseling and psychotherapy with Native American clients. In T. Smith (Ed.), Practicing multiculturalism: Affirming diversity in counseling and psychology (pp. 215-233). Boston: Allyn & Bacon.

Jafari, M. F. (1993). Counseling values and objectives: A comparison of Western and Islamic perspectives. American Journal of Islamic Social Sciences, 10, 326-339.

Kuhn, T. S. (1970). The structure of scientific revolutions (2nd ed.). Chicago: University of Chicago.

Kulis, S., Napoli, M., & Marsiglia, F. F. (2002). Ethic pride, biculturalism, and drug use norms of urban American Indian adolescents. Social Work Research, 26, 101-112.

Limb, G. E., & Hodge, D. R. (2008). Developing spiritual competency with Native Americans: Promoting wellness through balance and harmony. Families in Society, 89, 615-622.

Longabaugh, R., Donovan, D. M., Karno, M. P., McCrady, B. S., Morgenstern, J., & Tonigan, J. S. (2005). Active ingredients: How and why evidence-based alcohol behavioral treatment interventions work. Alcoholism: Clinical and Experimental Research, 29, 235-247.

Lowery, C.T. (1998).American Indian perspectives on addiction and recovery. Health & Social Work, 23, 127-135.

Lyotard, J.-F. (1984). The postmodern condition: A report on knowledge (G. Bennington & B. Massumi, Trans.). Minneapolis: University of Minnesota Press. (Original work published 1979)

Miller, G. (2003). Incorporating spirituality in counseling and psychotherapy. Hoboken, NJ: JohnWiley & Sons.

National Association of Social Workers. (2000). Code of ethics of the National Association of Social Workers. Retrieved July 28, 2003, from http://www. socialworkers.org/pubs/code/code.asp

Red Horse, J. (1997).Traditional American Indian family systems. Families, Systems, and Health, 15, 243-250.

Stiffman, A. R., Freedenthal, S., Dore, P., Ostmann, E., Osbore, V., & Silmere, H. (2006).The role of providers in mental health services offered to American-Indian youths. Psychiatric Services, 57, 1185-1191.

Stone, R.A.T., Whitbeck, L. B., Chen, X., & Johnson, K. (2005). Traditional practices, traditional spirituality, and alcohol cessation among American Indians. Journal of Studies on Alcohol, 67, 236-244.

Tjeltveit, A. C. (1999). Ethics and values in psychotherapy. New York: Routledge.

Trujillo, A. (2000). Psychotherapy with Native Americans: A view into the role of religion and spirituality. In R. E Scott & A. E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 445-466). Washington, DC: American Psychological Association.

U.S. Census Bureau. (2000). Census 2000 special tabulation. Retrieved December 28, 2006, from http:// www.census.gov/population/www/socdemo/race/ censr-28.pdf

Voss, R.W., Douville, V., & Little Soldier, A. (1999).Tribal and shamanic-based social work practice: A Lakota perspective. Social Work, 44, 228-241.

Walls, M. L., Johnson, K. D., Whitbeck, L. B., & Hoyt, D. R. (2006). Mental health and substance abuse services preferences among American Indian people of the Northern Midwest. Community Mental Health Journal, 42, 521-535.

Weaver, H. (2003). Cultural competence with First Nations peoples. In D. Lum (Ed.), Culturally competent practice (2nd ed., pp. 197-216). Pacific Grove, CA: Brooks/Cole.

Weaver, H. N. (2004).The elements of cultural competence: Applications with Native American clients. Journal of Ethnic and Cultural Diversity in Social Work, 13(1), 19-35.

Weaver, H. N. (2005). Explorations in cultural competence. Belmont, CA: Thomson Brooks/Cole.

Weaver, H. N., & Brave Hart, M.Y.H. (1999). Examining two facets of American Indian identity: Exposure to other cultures and the influence of historical trauma. Journal of Human Behavior in the Social Environment, 2(1/2), 19-33.

Whitbeck, L. B. (2006). Some guiding assumptions and a theoretical model for developing culturally specific preventions with Native American people. Journal of Community Psychology, 34, 183-192.

Yellow Bird, M. (2004). Cowboys and Indians: Toys of genocide, icons of American colonialism. Wicazo Sa Review, 19(2), 33-48.

David R. Hodge, PhD, is assistant professor, School of Social Work, Arizona State University, and senior nonresident fellow, Program for Research on Religion and Urban Civil Society, University of Pennsylvania, Philadelphia. Gordon E. Limb, PhD, is associate professor, School of Social Work, Brigham Young University, Provo, UT. Terry L. Cross, ACSW, LCSW, is executive director, National Indian Child Welfare Association, Portland, OR. Address correspondence to David R. Hodge, School of Social Work, Arizona State University, Mail Code 3251, 4701 West Thunderbird Road, Glendale, AZ 85306-4908.