M. Manson, Pembina Chippewa, PhD, Distinguished
Professor, directs the Centers for American Indian and Alaska Native
the Colorado School of Public Health
the University of Colorado Denver. His programs include
eight national centers that involve research, program
development and training in 102 Native communities,
including rural, reservation, urban and village
settings. Dr. Manson has published 160 articles on the
assessment, epidemiology, treatment and prevention of
physical, alcohol, drug and mental health problems in
this special population. He has received numerous awards
including 3 Distinguished Services Awards from the IHS,
the Rema Lapouse Mental Health Epidemiology
the American Public Health Association, the
Distinguished Mentor Award from the Gerontological
Society of America, the Herbert W. Nickens Award
the Association of American Medical Colleges, and the
George Foster Award for Excellence from the Society for
following interview was originally published in of
Winds of Change magazine.
Leader in Indian and Native Mental Health Research
What are the mental health issues facing Native
The environment in which most Indian people live is more stressful than any other environment in the United States. Death is a regular companion. There are vehicle accidents and many other accidents. The health care structures are spread thin. The safety net during times of crisis is inadequate.
There’s a growing awareness that grief and trauma can be transmitted through the generations. There is a wealth of literature now that indicates that even though the offspring of survivors of the Jewish holocaust did not have the direct experience of persecution in concentration camps, they are more vulnerable to trauma than offspring of non-Holocaust survivors. This work helps us understand how the offspring of Indian people who suffered the many atrocities of the United States government are still affected by these traumas, even though they are three or four generations removed from the actual experiences.
This is a backdrop that heightens Indian and Native people’s susceptibility and potential vulnerability to the consequences of other kinds of stressors that often pervade the world in which we live.
It’s not surprising then that, particularly in many rural reservation communities, there’s a high prevalence of alcohol, drug, and, mental health problems, including high rates of major depression at various points in the life cycle of Native people. There is a high rate of domestic violence and child abuse and neglect. Increasingly, there is also Elder abuse and neglect.
It is very important to stress that this is not a statement about moral weakness or characterlogical weakness of Indian and Native people. It’s a comment about the stressful nature of the social environment in which we live. In fact, it’s incredible that Indian and Native people are as resilient and vibrant and optimistic as they are. This really speaks to the strength of our people.
What kinds of mental health services are needed?
The environments in which Native people live are particularly impoverished compared to other environments in the United States. The amount of money that is spent on mental health care in the Native community is many times less than the amounts spent in the states of the union that provide the least amount of funding for mental health.
A study we reported in 1990 indicated that there were less than two dozen mental health child specialists in Indian country. With special congressional appropriations, that number has probably doubled, but even if the number of specialists increased ten fold, it would still be dramatically less than what is needed.
Many initial mental programs were office-based. This is not a good fit with the Indian community. Gradually models have been developed that emphasize outreach.
What is the importance of reaching out? Unlike the great strides that we’ve made in destigmatizing alcohol abuse and dependence, we have not made that same progress in destigmatizing mental illness. People are reticent, even afraid to go to the mental health programs, which are often housed in trailers attached to the local clinic. Doing so, they fear, will single them out as being “crazy”. This speaks to the deep-seated stigma around mental illness, which only now is beginning to change through the remarkable grassroots efforts of people like Marla Bull Bear, Rosebud Sioux, and others like her.
It’s quite common now in many meetings for Indian people to get up and to talk about their alcoholism, their recovery and road to sobriety. But you still rarely hear Indian people acknowledge their own current or past mental illness and share their struggles and triumphs. Until we reach that point, regardless of how many mental health services we fund and how many studies we have, few of these programs will have any real effect.
Are there any special roles that Native American professionals can play in all of this?
There are many, many roles. The first thing to recognize is that education, education, education is the most important thing we can do. We have to educate our leaders – both formal and informal – about the true picture of mental health and illness in our community. We also have to educate providers and various other stakeholders in our community.
For example, co-morbidity–the concurrent experience of an alcohol and a mental health problem—is more the rule than the exception. But the way that treatment is organized, funded, and carried out doesn’t acknowledge this. Some providers deal with alcoholism as if it was the only problem. Others deal with a mental health problem, such as conduct disorder, on its own. Each provider remains blinded to the presence and the importance of problems other than the one that she or he is focused on.
In regional adolescent substance abuse treatment centers, we find that fully one-third to one-half of the youth in treatment suffer co-morbid mental disorders, typically depression, post traumatic stress disorder, or conduct disorder. Unless these mental health problems are addressed at the same time that the substance abuse is addressed, they are highly likely to return months later.
In this country, primary care physicians and nurses are usually the first people who encounter a mental health problem. They probably also see most mental health problems, but many of them are not well equipped to recognize and treat these problems. Even when they do recognize them, they often do not manage them well. For example, they are likely just to prescribe drugs, and we know that pharmacological interventions aren’t always the best intervention. Psychiatric or other kinds of mental health interventions are usually also needed.
Many people who are in detention facilities, such as jails and lockups, suffer from mental health problems that go unrecognized and keep them at risk for delinquent or antisocial behaviors. We’ve done a couple of major studies in which fully half of youth in reservation-based detention facilities suffer from alcohol, drug or mental health problems. It’s very clear that the children who are booked repeatedly have a greater presence of and severity of emotional and psychological problems.
In schools we often focus on educational difficulties, but we don’t also think about psychological difficulties that may impair a youth’s ability to be part of that environment and to engage in the learning process. Evidence is building rapidly that many Native youth in our schools suffer from a wide range of emotional and psychological problems that impair their ability to learn and to participate fully in their education.
It’s very important that we move beyond our current ways of thinking about mental health and mental health care. We need to recognize that mental health problems arise in a variety of settings. They aren’t simply the problem of mental health providers. This underscores the importance of linkages among mental health providers, teachers, primary care providers, and detention officers.
The world in which Indian people live also includes the spiritual. A number of model programs in tribal communities seek to care for the mental and spiritual aspect as well as the body. We have many examples in which mental health providers have formal or informal links with people from the local spiritual traditions, for example traditional healers, medicine people, roadmen, or fundamentalist Christian healers.
Is there are need for more Native Americans in the mental health professions?
There is definitely a need for more Indian and Native people in the clinical arena. And we need them in the research area as well. Their involvement will lead to a better understanding of the nature and extent of such problems, their root causes and how we can treat as well as prevent them. We then need to take this knowledge and apply it in a systematic way.
This article was originally published in the Summer 2000 issue of Winds of Change.
On January 1, 2009, the Centers for American Indian and Alaska Native Health (formerly the American Indian and Alaska Native Programs) moved from the School of Medicine, Department of Psychiatry to the Colorado School of Public Health on January 1, 2009. Dr. Manson said that the move offered a “natural intellectual landscape” for the Centers work, most of which “focuses on community-based epidemiological and preventive intervention research.”
The Centers programs are described on their web pages.
Center of Excellence in Eliminating Health Disparities
The goal of this project is to reduce cardiovascular risk among urban American Indians and Alaska Natives.
Center for Native American Telehealth and Tele-education
This national program employs state-of-the art telecommunication technologies in addressing high priority health-related service, education, and research needs of American Indian and Alaska Native communities.An important component of the program is teaching local people to use these technologies so local people can shape the use of these technologies to their needs.
Center on Native Elder Health Disparities
The center promotes excellence in research and research capacity building to improve the health of older adults in American Indian and Alaska Native communities.
Circles of Care
This program supports American Indian and Alaska Native communities that are developing initial health service programs for children with serious emotional and behavioral disturbances.
This project promotes high quality, culturally competent, theoretically, and programmatically relevant research through projects that promise to shed light on the barriers and facilitators involved in improving the health status and functioning of older American Indians and Alaska Natives.
The American Indian and Alaska Native Head Start Research Center
Native Elder Research Center /Resource Center for Minority Aging Research
The Special Diabetes Program for Indians
For more information, see the Centers for American Indian and Alaska Native Health website.