Mental Health and Substance Abuse
Services Preferences among American
Indian People of the Northern
Melissa L. Walls, M.A.
Kurt D. Johnson, Ph.D.
Les B. Whitbeck, Ph.D.
Dan R. Hoyt, Ph.D.
ABSTRACT: This study examines factors that influence preferences between
traditional cultural and western mental health and substance use associated care
among American Indians from the northern Midwest. Personal interviews were
conducted with 865 parents/caretakers of tribally enrolled youth concerning their
preferences for traditional/cultural and formal healthcare for mental health or
substance abuse problems. Adults strongly preferred traditional informal services to
formal medical services. In addition, formal services on reservation were preferred to
off reservation services. To better serve the mental health and substance abuse
treatment needs of American Indians, traditional informal services should be
incorporated into the current medical model.
KEY WORDS: service utilization; American Indians; mental health; substance abuse.
Melissa L. Walls, Kurt D. Johnson, Les B. Whitbeck, Dan R. Hoyt are affiliated with the
Department of Sociology, University of Nebraska-Lincoln, 711 Oldfather Hall, Lincoln, NE 68588-
Address correspondence to Melissa L. Walls, M.A., Department of Sociology, University of
Nebraska-Lincoln, 711 Oldfather Hall, Lincoln, NE 68588-0324, USA; e-mail: mwalls@unl-
Community Mental Health Journal, Vol. 42, No. 6, December 2006 (? 2006)
? 2006 Springer Science+Business Media, Inc.
A 2001 supplemental report on mental health to the Surgeon General
describes the current United States public health perspective as a
‘‘population-based approach (that) is concerned with the health of the
entire population, including its link to the physical, psychological,
cultural, and social environments in which people live, work, and go to
school (Dept of Health and Human Services (DHHS), 2001).’’ This
statement reflects a concept of holistic healing in a time of growing
acceptance and utilization of alternative or complimentary health
services beyond those available within professional medical systems.
Rodenhauser (1994) notes that although psychiatry as a specific med-
ical field shows increasing cultural awareness regarding clinical sen-
sitivity within the academic literature, there has been little to no
evidence of cultural factors found within mainstream journals for
health administrators. In addition, very little research is available
concerning the co-utilization of ‘‘alternative’’ and western medical ap-
proaches, let alone an examination of this overlap within specific cul-
tures (Gurley et al., 2001; Rhoades & Rhoades, 2000; but see Novins,
Beals, Moore, Spicer, & Manson, 2004). An understanding of these
services may be especially important within an American Indian cul-
tural context where traditions often involve complex ceremonies and
beliefs that require consideration far beyond that of mainstream reli-
gion (Rhoades & Rhoades, 2000).
The purpose of this study is to examine factors that influence the
choice between traditional cultural and western mental health and
substance use associated care among American Indians from reserva-
tions in the northern Midwest. Specifically, we examine preference in
terms of perceived effectiveness and actual utilization of traditional vs.
Western-based service outlets.
Barriers to Health Services
American Indians and Alaskan Natives have been found to report
highest rates (12.9%) of frequent mental distress among all ethnic
groups, including Hispanics (10.3%), African Americans (9.7%), Whites
(8.3%), and Asian/Pacific Islanders (6.1%) (Centers for Disease Control
(CDC), 1998). The 2000–2001 National Household Survey on Drug
Abuse found American Indians/Alaskan Natives to be second only to
multi-ethnic individuals to have received mental health treatment in
the past year. At the same time, American Indian/Alaska Native
522Community Mental Health Journal
respondents were second highest among all ethnic groups who had not
received mental health care to report perceived unmet service needs
(Barker et al., 2004). A similar pattern is found for substance abuse
where again, American Indians/Alaskan Natives are second to multi-
ethnic persons in terms of prevalence of illicit drug or alcohol depen-
dence (Substance Abuse and Mental Health Services Administration
A majority of Indian people within the United States receive physical
and mental healthcare from Indian Health Services (IHS) (Gone, 2004).
IHS’s Indian Health Care System served around 1.6 million American
Indians/Alaska Natives residing on or near reservations in 2003 (IHS,
2003). Over one-third of service utilization within this system involves
mental health and social service related concerns (IHS, 2002). Although
Indian Health Services is meant ‘‘to raise the physical, mental, social,
and spiritual health of American Indiana and Alaska Natives to the
highest level’’ (IHS, 2002), a variety of barriers may impede American
Indians’ ability to receive adequate health care. Specific to mental
health care delivery, and often overlapping with the characteristics of
healthcare in general, Rodenhauser (1994) characterizes barriers into
two major groups: (1) those within the current medical system,
including under-funding and staffing issues, inconsistent services,
insensitivities, fear of litigation and non-compliance with organiza-
tional requirements, and staff burnout; and (2) those inherent to
American Indian/Alaska Native cultures, such as fear, high rates of
accidents/violence, intrinsic conditions (i.e. denial, helplessness and
hopelessness), and mistrust of government agencies.
Traditional Help Seeking
Research and anecdotal evidence suggests that many American Indi-
ans report health related help-seeking via culturally traditional out-
lets. For example, Marbella, Harris, Diehr, Ignace, and Ignace (1998)
surveyed 150 American Indian adult patients at the Milwaukee Indian
Health Center and found that 38% had sought help from a traditional
healer in addition to physician-administered care. Furthermore, 86% of
those interviewed said that they would consider seeking a traditional
healer in the future. In instances where traditional healer’s and phy-
sician’s advice differed, patients said they would rely on their healer’s
advice 61.4% of the time. In a separate study including respondents
from 2 different American Indian tribes, Novins, Beals, Moore, Spicer,
and Manson (2004) found traditional healing options to be prevalent
Melissa L. Walls, M.A., et al.523
and important to both tribes, whether used alone or in combination
with biomedical services.
Although traditional beliefs and practices can guide some American
Indians through mental and physical illnesses and healing, there is
disagreement concerning the degree of connection between traditional
and professional medical services at an institutional level. A number of
researchers discuss a gap wherein the processes of traditional and
mainstream professional healing should be linked (Marbella et al.,
1998; Mohatt & Varvin, 1998; Novins, Beals, Sack, & Manson, 2000;
Novins, Fleming, Beals, & Manson, 2000). Conversely, others feel that
formal funding for traditional practices is difficult and perhaps inap-
propriate. Payment to a traditional healer by a patient may be com-
promised in a situation where billing must occur via a third party.
Issues surrounding payment are complicated further considering the
need to establish credentials for employees of government funded
agencies like IHS (Rhoades & Rhoades, 2000). It is also important to
consider the heterogeneity of the over 300 different tribal or language
groups from which American Indian individuals belong (Beauvais,
1998). Tribal differences extend to various opinions regarding an
integration of the two health care systems (Rhoades & Rhoades, 2000;
see also Novins et al., 2004).
Despite some documentation on the preference of traditional vs.
western medical treatment among American Indians who receive both,
we found little empirical evidence that directly tests the factors that
affect this choice (but see Gurley et al., 2001; Novins et al., 2004; Robin,
Chester, Rasmussen, Jaranson, & Goldman, 1997). In addition, there is
a lack of empirical research surrounding American Indian mental
health/substance use related services utilization (Manson, 2000), and
what work has been done typically focuses on Indian children (i.e.
Novins, Harman, Mitchell, & Manson, 1996; Costello, Farmer, Angold,
Burns, & Erkanli, 1997; Novins et al., 2000). This research begins to
address such gaps in the literature by examining predictors of service
preferences among a sample of American Indian adults.
In a review of the literature, Manson (2000) includes differences related
to culture (i.e. acculturation vs. enculturation) as important predictors
of formal mental health service utilization. Elsewhere, higher levels of
social support (here measured as community support) have been shown
to be related to receiving a treatment recommendation for substance
524 Community Mental Health Journal
use problems (Novins et al., 1996); in turn, being recommended for
treatment may increase actual service utilization. In addition, rates of
mental health treatment have been found to be higher for adults with a
lower perceived health status (Barker et al., 2004).
Based on these findings and coupled with the barriers to care dis-
cussed earlier, we hypothesize that higher levels of enculturation,
experiencing discrimination, and living on a reservation will be posi-
tively related to perceived effectiveness or preferences for informal
services and negatively related to formal services. In addition, self-
reported physical health is hypothesized to be negatively related to
preferences of both service types (Barker et al., 2004). We also predict
that higher levels of social support will be positively related to use of
both informal and formal service outlets. Lastly, we control for the
effects of age, gender, education, and employment on service utilization
These data were collected as part of the ‘‘Healing Pathways Project,’’ a 3-year lagged
sequential study currently underway on four American Indian reservations in the
Northern Midwest and five Canadian First Nation reserves. Because of national dif-
ferences in health care systems, the data presented here includes only that from U.S.
reservations. The data are from wave one of the study collected on two U.S. reserva-
tions from February through October 2002, and wave one on a second pair of U.S.
reservations collected from February through October 2003. The reservations share a
common cultural tradition and language with minor regional variations in dialects. The
sample represents one the most populous Native cultures in the United States and
The project was designed in partnership with the participating reservations and
reserves. Prior to the application funding, the research team was invited to work on
these reservations, and tribal resolutions were obtained. As part of this agreement, the
researchers promised that participating reservation names would be kept confidential
in published reports. An advisory board was appointed by the tribal council at each
participating reservation and is responsible for advising on difficult personnel prob-
lems, questionnaire development, reading reports for respectful writing, and assuring
that published reports protected the identity of the respondents and the culture. Upon
advisory board approval of the questionnaires, the study procedures and question-
naires were submitted for review and approved by an Institutional Review Board. All
participating staff on the reservations were approved by the advisory board and were
either tribal members themselves or non-members who are spouses of tribal members.
To ensure quality of data collection, all interviewers underwent special training for
conducting pencil-and-paper and computer-assisted personal interviewing for diag-
nostic measures, including feedback sessions. In addition, all of the interviewers
completed a required human subject’s protection training that emphasized the
Melissa L. Walls, M.A., et al.525
importance of confidentiality and taught procedures to maintain the confidentiality of
Each tribe provided lists of families of enrolled children aged 10--12 years who lived
on or proximate to (within 50 miles) the reservation or reserve. We attempted to con-
tact all families with a target child within the specified age range. Families were
recruited via personal visits from Native interviewers during which they were given an
explanation of the project, a gift of wild rice, and an invitation to participate. After
agreement to participate and later completion of interviews, each participating family
member received $40 for their time. This recruitment procedure resulted in an overall
response rate of 79.4%.
The sample for this analysis is made up individuals from the U.S. reservations only and
consisted of 865 parents/caretakers (264 males and 601 females) of tribally enrolled
children aged 10--12 years. Fathers/male caretakers ranged in age from 21 to 70 years
with an average age of 42 years; mothers/female caretakers ranged in age from 17 to
78 years with an average of 39 years.
Toassess theperceivedeffectivenessofhealthservice providers,respondents weregiven
a series of questions asking them how effective various service outlets would be if ever
there were to have (1) an emotional problem, or (2) a substance abuse problem. The
response categories range from not at all effective to extremely effective. Traditional/
tobacco, traditional healer, traditional ceremony, and healing circle. Formal services
include Indian Health Service (IHS), doctor, psychologist, social worker, counselor,
psychiatrist, chemical dependency counselor, and nurse. Respondents were asked to
evaluate the perceived effectiveness of formal services both on and off the reservation.
services: (1) traditional, (2) formal on reservation, and (3) formal off reservation, all
within each realmofservice need(emotional andsubstance abuse). Eachmeanscorehas
a range from 1 to 5, with higher scores indicating greater perceived effectiveness.
Enculturation is a latent construct assessed by three basic elements: (1) participa-
tion in traditional activities, (2) identification with American Indian culture, and (3)
traditional spirituality (see Costello et al., 1997; Whitbeck, McMorris, Hoyt, Stubben,
& LaFromboise, 2002). The enculturation scale has high internal consistency (Cron-
bach’s a = .79), and the standardized version of the scale is used in these analyses.
Perceived discrimination is measured with an 11-item scale designed to tap a
range of potential types and sources of discrimination. Respondents were asked to
report how often they had experienced specific instances of discrimination. Those
items included in the scale were; how often someone said something derogatory or
insulting because of your race; how often a store owner, sales clerk or person
working at a business has treated you in a disrespectful way because of your race;
how often the police have hassled you because of your race; how often you have been
ignored or exclude from an activity because of your race; how often someone has
yelled a racial slur or racial insult at you; how often someone threatened physical
harm because of your race; how often someone suspected you of doing something
wrong because of your race; how often you have been treated unfairly because of
your race; how often you have encountered whites who didn’t expect you to do well
526Community Mental Health Journal
because of your race; how often someone discouraged you from trying to achieve an
important goal because of your race; and how often you have been treated unfairly
in the courts because of your race. The four response categories range from never to
always, with the mean of all 11 items used in these analyses. The scale has a high
internal reliability with Cronbach’s a of .90.
Social support is measured with a 17-item scale in which respondents were read
statements regarding community and neighborly cohesiveness and conflict. Statements
include: this is a close knit community; people around here are willing to help their
neighbors; there are adults in this community that children can look up to; there are
long standing family grudges in the community; the community is split by politics; the
community is split by alcohol or drugs; and so on. Respondents were asked to answer
true or false to each statement. Items indicative of community conflict were reverse
coded, and then all items were summed so that higher values represent higher com-
munity support. Cronbach’s a for this scale is .86.
Health status was assessed by response to the question ‘‘In general, how well would
you say your health is?’’ Response categories ranged from excellent (5) to poor (1).
Values are coded so that higher scores indicate better health.
Several control variables are included in the present analysis. Gender is a dummy
variable coded as male = 0 and female = 1. Education is a five category item ranging
from less than high school to an advanced degree. Employment is a dichotomous var-
iable indicating if the respondents are employed full-time. Those with full-time
employment are coded as 1. To assess the difference between those enrolled tribal
members living on and off the reservation respondents were asked if they currently
lived on the reservation at the time of their interview. Those who lived off of the
reservation were given a value of 1.
The adults who comprised this sample had an average educational level
falling between a high school diploma and at least some secondary
school experience (mean = 2.4; SD = .87), and more than half (57%)
were employed full-time. Very few of the adults lived off of the reser-
vation (12%) at the time of our interviews. The self-reported health
status of the adults in our sample averaged between ‘good’ and ‘very
good’ (mean = 3.3; SD = 1.0), and the overall level of reported social
support in the communities was 8.4 (SD = 4.1). Enculturation is a
standardized variable in these analyses (mean = 0; SD = 1), while the
mean level of perceived discrimination was 1.5 (SD = .69), indicating
that the average response across all of the discrimination questions fell
between ‘never’ and ‘a few times.’
services for both mental health (mean = 3.06; SD = 1.06) and substance
Melissa L. Walls, M.A., et al.527
use (mean = 3.09; SD = 1.15) related issues. Next highest were mean
health = 2.51; SD = 1.01; substance use = 2.53; SD = 1.09), followed
health = 2.32; SD = 1.03; substance use = 2.34; SD = 1.09).
Perceived Effectiveness of Services
Figure 1 illustrates the perceived effectiveness of services that are
commonly used for mental health or substance abuse problems. The
reported percentage indicates those respondents who felt the services
would be very or extremely effective. There is a clear distinction of the
perceived effectiveness between informal or traditional services and
more formal services. Seventy-one percent of respondents felt that
talking to a family member would be very or extremely effective. Nearly
60% felt talking to a tribal elder would be highly effective for dealing
with mental health or substance problems. More traditional practices/
services such as offering tobacco and praying, seeing a traditional
healer, traditional ceremonies, healing circle, sweat lodge, and pipe
ceremony all were rated between 30% and 50%. Speaking to a counselor
on the reservation was the highest rated professional service with
32.9% of respondents indicating it would be very or extremely effective.
Most of the on reservation professional services rated higher than
services off the reservation but lower than more traditional services.
Those services that were seen as least effective were those professional
services located off of the reservation.
Use of Informal and Formal Services
Table 1 reports the coefficients from ordinary least squares regression
analyses for predictors of respondent perceptions of the effectiveness
(i.e. preferences) of informal traditional and formal services for sub-
stance abuse and mental health concerns. Because this sample contains
some cases where two adult reporters were interviewed within a
household, reported coefficients are based on standard errors that have
been adjusted to account for the potential bias of nested designs
(analyses performed using STATA 7.0). The same sets of variables
significantly predict informal service preference for both mental health
(MH, Model 1A) and substance use (SU, Model 1B) related problems.
For both models, females were more likely to prefer informal services
(MH: b = .06, p<.05; SU: b = .05, p<.10), as were the employed (MH:
528 Community Mental Health Journal
b = .07, p<.05; SU: b = .07, p<.05). For both Model 1A and 1B, higher
rates of social support (MH: b = .13, p<.001; SU: b = .13, p<.001),
higher enculturation scores (MH: b = .49, p<.001; SU: b = .44,
p<.001), and higher reports of perceived discrimination (MH: b = .09,
p<.01; SU: b = .11, p<.01) were all positively associated with informal
Moving to predictors of formal service preferences on reservations
(Models 2A & 2B), higher levels of social support were a significant
predictor in both the MH (b = .13, p<.001) and SU (b = .17, p<.001)
Perceived Effectiveness of Services.
Percent indicating very or extremely effective
Social worker off Reservation
Nurse off Reservation
Psychiatrist off Reservation
Social worker on Reservation
Psychologist off Reservation
Counselor off Reservation
Nurse on Reservation
Psychiatrist on Reservation
Doctor off Reservation
Indian Health Service
Psychologist on Reservation
Doctor on Reservation
Counselor on Reservation
Offering to bacco and praying
Talking to an Elder
Perceived Effectiveness of Services
Melissa L. Walls, M.A., et al.529
OLS Regression Models Predicting Perceived Effectiveness (Preferences) of Mental Health and Substance Use Related Services
(female = 1)
+p<.10; *p<.05; **p<.01; ***p<.001 (two-tail test).
Sample size across models ranges from n = 803 to n = 822 after listwise deletion.
530Community Mental Health Journal
models, as were higher rates of perceived discrimination (MH: b = .07,
p<.10; SU: b = .10, p<.01) and education (MH: b = .12, p<.01; SU:
b = .13, p<.001). Age is significantly associated with formal on-reser-
vation service preferences only for substance use problems (b = .06,
p<.10), whereas females are more likely than males to prefer on-res-
ervation formal care in the case of mental health problems (b = .06,
Models 3A and 3B illustrate the coefficients for predictors of formal
off-reservation service preferences. Both models contain similar find-
ings: higher education (MH: b = .18, p<.001; SU: b = .15, p<.001),
living off of reservation lands (MH: b = .09, p<.05; SU: b = .14,
p<.001), and higher levels of social support (MH: b = .08, p<.05; SU:
b = .09, p<.05) were all positively associated with higher preferences
for formal off-reservation services. In addition, Model 3B shows that
those who scored higher on levels of traditional enculturation were less
likely to perceive formal off-reservation care as effective in terms of
substance use related problems (b = ).07, p<.05).
Across all of the models in Table 1, the independent variables explain
proportionately more of the variance for the informal service models
than those with formal services as the dependent variable. Adjusted R2
values for these models indicate that the predictors explain 28% and
24% of the variance in informal service preferences for MH and SU
problems, respectively. These values for formal reservation-based care
are 4% for MH and 5% for SU problems. The models for formal off-
reservation care explain 5% of the variance in preferences for MH
problems and 6% of the variance for SU problems.
The adults in our sample felt that more culturally traditional services
(such as family or a traditional healer) would be more effective than
either professional services on the reservation, or professional services
off the reservation. Off reservation services were perceived to be least
effective. These findings support literature that suggests American
Indians generally place considerable trust in traditional practices (i.e.
Marbella et al., 1998). The finding that mainstream professional ser-
vices are perceived as less effective than traditional informal services
and some of the on-reservation professional services underlies the
previous discussion surrounding issues of trust and appropriateness of
Western care in relation to American Indian cultures. It is also possible
Melissa L. Walls, M.A., et al.531
that a crisis-oriented care system may not be suited to adequately deal
with mental health and substance abuse needs (Oetting & Beauvais,
The multivariate analyses supported several of our hypotheses.
Among the control variables, females were slightly more likely than
males to report higher preference for both (MH & SA) types of informal
care, as well as for on-reservation MH care. Though not explicitly
hypothesized, these results correspond with previous help-seeking re-
search that has found women more likely than men to view care as an
appropriate remedy for psychological issues (Horwitz, 1987). Higher
educational levels and employment were generally related to higher
effectiveness ratings for services in this study, also corroborating pre-
vious research (see, for example, Horwitz, 1999, p. 66).
As expected, those who are more enculturated were more likely to
utilize informal traditional services than those who are less encultur-
ated. In addition, in the case of services for substance use disorders,
higher levels of enculturation were negatively associated with prefer-
ences for formal off-reservation care (Model 3B). Those who lived off the
reservation were more likely to use formal services, especially in terms
of off-reservation care. Consistent with past research (Novins et al.,
1996) and as hypothesized, perceived social support was positively
associated with higher perceptions of effective care across all types of
services. Our hypothesis that higher rates of perceived discrimination
would be associated with preferences for informal or traditional care is
supported here. We found similar effects for discrimination and formal
on-reservation care. These findings are congruent with Rodenhauser’s
(1994) description of the barriers to dominant-culture care in terms of
mistrust of government agencies, all stemming from a history of colo-
nization and continued institutional racism experienced by many
American Indian peoples (see, for example, Duran & Duran, 1995).
Overall, the results of this study highlight a preference for informal or
culturally based care, especially among the enculturated.
The differences in the proportions of variance explained across each of
the models in Table 1 warrant discussion. These analyses include only
one measure of cultural identity: enculturation. As discussed, this
measure was significantly associated with ratings of informal service
preference, but did little in terms of predicting formal service prefer-
ences. It may be that an important predictor of formal services is accul-
532 Community Mental Health Journal
measures to further our understanding of how cultural identity affects
service preference and utilization (see Novins et al., 2004).
Although we interviewed a broad range of American Indian adults on
multiple reservations that are dispersed geographically across two
Midwestern states, these results pertain to a single culture and capture
variations within this culture. We believe the findings represent the
culture well, but they cannot be generalized to other Native cultures. A
second caution regarding the sample is that it is made up of parents
and caretakers of children aged 10--12 years. This could reflect a
selection bias in that parents/caretakers may be more likely to utilize
services and to be currently mentally healthy and alcohol and drug free
than individuals with no children. Finally, all of our measures are
based on self-reports. We did not have access to service utilization rates
from local clinics or reports of services use from traditional healers.
These findings have important policy implications for those who pro-
vide health services to American Indian people. Cultural traditions are
very much alive on U.S. reservations and are preferred methods of
healing for mental health or substance abuse problems. This should be
taken into account when designing health services systems either by
providing alternative services onsite or through creatively engaging
informal traditional services. Simply acknowledging informal service
providers by asking the patient if they have seen a traditional healer
and then contacting him or her for an opinion would be an important
step. Health providers could include key community spiritual leaders
and healers on health advisory boards or create health partnerships
that would encourage mutual referrals. Perhaps the place to begin
would be to respectfully seek the advice of elders on decreasing barriers
between the two.
Actual integration of services is already taking place on many res-
ervations, but implementation is not always straight forward (Mara-
bella et al., 1998; Mohatt & Varvin, 1998; Rhoades, & Rhoades, 2000).
Issues about selection of traditional healers, and how to reimburse
them such as whether they should charge fees for services and coverage
for third party payments must be worked out culture by culture. Some
view such integration as a potential acculturation risk.
Melissa L. Walls, M.A., et al.533
Changing the current short comings in mental health delivery first
involves acknowledging that parallel systems exist in some cultures.
The impetus for change may have to come from formal services
providers who should demonstrate respect for traditional healers, in-
vite their advice, and consult with them if patient’s give permission.
Clinicians may need to be proactive in offering their patients this op-
tion rather than waiting for the patient to request it. Creating this
sensitivity may require specialized training for services providers on
American Indian reservations. Grant funding groups may want to
consider supporting model programs that bring together the two
There is much to be done to increase American Indians’ confidence in
health services systems. One avenue for this would be to work more
closely with informal traditional services that are trusted. We need
control group trials of innovative services models that cross over be-
tween formal medical services and traditional approaches to healing to
assess the efficacy of combining the approaches. Continued failure to
acknowledge the strong preferences for traditional ways is to ignore a
valuable health resource.
This research was funded by the National Insitute on Drug Abuse (DA
13580) and the National Insitute Of Mental Health (MH 67281), Les B.
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