In our ever-evolving multicultural society, it is critical for providers to engage with patients and their families with sensitivity and empathic awareness of their social and historical backgrounds. While the specifics of each group’s experiences and needs will vary, providing effective quality care should reflect congruence with the practices described herein.
Partnering with American Indian and Alaska Native (AI/AN) youth and families can lead to a highly satisfying, meaningful, and rewarding encounters. The term “partnering” is quite intentional, as it sends the message that we are working “with” a patient rather than “on” a patient. AI/AN patient populations are ethnically, geographically, and socially diverse. This diversity and cultural complexity adds a richness to clinical care that can be quite satisfying. Providers caring for AI/AN youth and families are able to help individuals who have historically been underserved, under-resourced, and in some cases, completely forgotten. In some cases, a very small amount of help can go a tremendously long way.
Providers should be aware of some helpful guidelines when joining with AI/AN patients. The first is to resist any inclinations to make broad assumptions about AI/AN youth and families. This can be easier said than done, as each tribe has its own defining history, cultural practices, and identity that are unifying. Healthcare practitioners can quickly fall prey to thinking “this tribe is like this” and “that tribe is like that.” While we do want to respect cultural differences, we want and need the patients themselves to guide us. Some AI/AN families may adhere very closely traditional practices, while others may identify more with modern life in the United States. It is of the utmost importance that the patient themselves are able to identify what their culture means to them, and for the healthcare team member to follow the patient’s lead.
The unimaginable historical trauma experience of AI/AN populations as a whole must be acknowledged. AI/AN populations have been through multiple generations of trauma, discrimination, abuse, and neglect, at the hands of governmental and civilian figures of authority. The healthcare system itself has conducted research on AI/AN populations without consent. As a result, it is quite understandable that some AI/AN patients may have a general mistrust in the medical system or when interfacing with authority figures.
Thus, utilizing a trauma-informed care approach is of the utmost importance in AI/AN treatment settings. Trauma-informed care is a theoretical framework that encourages providers to presume that each patient with whom they interact has more likely than not had experienced some form of trauma in their lives. The five guiding principles of trauma-informed care are as follows: safety, trustworthiness, choice, collaboration, and empowerment.
Safety and trustworthiness are built by showing respect to patients and their families, and being completely transparent from the start. Patient-blaming terminology such as “non-compliance,” “non-adherence,” can be shifted to objective reporting, such as “due to psychosocial barriers, patient currently taking medications three times per week”. Similarly, phrases like “difficult patient,” or “challenging family” should be avoided. Consider phrases such as, “the patient or family is dealing with a difficult situation at this time.” Here, the situation is described as “difficult” rather than the patient or family. Similarly, stating “our treatments have not been effective for this patient” comes across quite differently than “the patient has failed treatment on five medications.” Rather than stating a patient has “poor concentration,” we can state that “the patient reports challenges in concentrating.” These shifts in language can help build trust with the medical system. Similarly, our non-verbal body language should convey values of openness, acceptance, empathy, and compassion. We should create shared physical spaces in clinics that enhance health, wellness, and healing for our AI/AN clients.
The trauma-informed principles of choice, collaboration, and empowerment highlight the importance of community-based, inclusive decision making. Minority populations who have experienced historical trauma may experience a mistrust of authority figures and the medical system. A paternalistic approach in which providers believe they know what is best for the patient is least likely to be effective in this case, because it can be re-traumatizing and re-emphasizes the history of colonization and violated trust. When working with AI/AN youth and families, patient autonomy in medical decision making is paramount. When making larger healthcare decisions that impact multiple patients, a community-based approach should engage community stakeholders to guide outcomes.
Recognizing that rules and regulations can vary considerably from location to location can help healthcare providers offer care that is congruent with existing sovereign tribal rights and responsibilities. This is particularly true of medical and psychiatric emergencies where compliance with tribal and cultural rights better enable safe and effective care.
Healthcare providers who work with AI/AN families should have a strong working knowledge of local systems including tribal schools, social services, correctional services, and healthcare services. In some instances, the U.S. Bureau of Indian Education or the U.S. Bureau of Indian Affairs may be involved. In other instances, policies and procedures will be maintained by tribal governors and elected officials. Many AI/AN families may receive some services on a reservation, and travel off of a reservation for other services. Access to care can be the largest barrier for some AI/AN patients. System to system cooperation and collaboration is required to insure that the greatest amount of care reaches the largest number of families in need as possible.
As with all patient care, the practice of partnering with youth and families with understanding of their cultural and historical background can lead to better clinical outcomes and be a rewarding experience. Following the aforementioned guidelines will help to build strong relationships with patients, healthcare staff, and the larger communities who we serve.