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Community Mental Health Journal, Vol. 33, No. 4, August 1997

Domestic Violence Intervention in an Urban Indian Health Center Ilena M. Norton, M.D. Spero M. Manson, Ph.D.

ABSTRACT: This report describes a domestic violence program in an urban Indian health center. The failure of office-based interventions and the importance of developing interventions that are sensitive to the needs of this population is discussed. Successful interventions including home visits and a domestic violence group that incorporated American Indian traditions and values are presented.

INTRODUCTION In 1991 the Indian Health Service issued a report that family violence is a serious problem in Indian communities (Indian Health Service, 1993). The first shelter on an Indian reservation was opened in 1977 by the White Buffalo Calf Women's Society of the Rosebud Reservation (DeBruyn, Wilkins, & Artichoker, 1990). Subsequently, a number of reservation and urban communities have started local programs in response to the problem of domestic violence. Despite the increasing recognition of domestic violence in American Indians communities, the literature on domestic violence interventions in this special population is almost non-existent. Dr. Norton is an Assistant Professor, Denver Health Medical Center and the National Center for American Indian and Alaska Native Mental Health Research (NCAIANMHR), University of Colorado Health Sciences Center. She has received funding from the Program for Minority Research Training, American Psychiatric Association. Dr. Manson is Professor and Director, NCAIANMHR, Department of Psychiatry, University of Colorado Health Sciences Center. Reprint requests should be addressed to Dr. Ilena Norton, NCAIANMHR, Box A011-13, University North Pavilion, 4455 E. 12th Avenue, Denver, CO 80220. 331

© 1997 Human Sciences Press, Inc.

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Community Mental Health Journal

American Indians and Alaska Natives are a diverse group represented by over 500 tribes with significant differences in tribal customs, language and family structure. Numbering approximately 2 million, one-quarter live on federal Indian reservations and the remainder in off-reservation rural areas or cities (U.S. Bureau of Census, 1991). After World War II, many reservation Indians were forced to resettle in urban centers. In the current day, significant migration between reservations and cities continues. This paper describes a domestic violence program located in an urban Indian health center. The Indian Health Service provides funding for urban health centers in over 30 states through a small contract program. The goal of these health centers is to facilitate access to health care and public assistance programs, although many centers also provide direct services by supplementing the IHS funds through other public and private grants (U.S. Office of Technology Assessment, 1986). DESCRIPTION OF THE PROGRAM This report is based on the first author's (IN) experience consulting to a domestic violence program at an urban Indian health center During her initial contact with the program in 1989, the health center provided a range of services including a medical clinic with a full-time nurse practitioner, social service program, mental health and alcohol prevention programs. The domestic violence program was staffed by two American Indian women, who occupied the positions of program supervisor and victim advocate. Fiscal support derived from small contracts with the state division of alcohol and drug abuse programs, and the division of criminal justice. The domestic violence program staff provided social service interventions such as housing, emergency clothing, and transportation to appointments. The program supervisor was a supportive listener and provided individual counseling and even crisis housing at her own home. Initially, a few women were referred to IN for counseling by the nurse practitioner in the medical clinic. In these first attempts to counsel battered women, the women would attend at most one to three individual sessions at the health center, and then not return for scheduled appointments. Obvious impediments included transportation and child care problems, but more importantly, the women seemed distant and disconnected in interactions with the counselor. Attempts to con-

Ilena M. Norton, M.D. and Spero M. Manson, Ph.D.

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duct a domestic violence group with the victim advocate also were not successful. The group was educational in nature, addressing domestic violence topics, inviting local speakers, and viewing films. Although this group generated some initial interest, it quickly dwindled to minimal or no attendance. After the program supervisor left the center, IN returned in 1991, volunteering up to ten hours per week to counsel women and supervise the victim advocate. Because of the earlier experience with poor client return rates, we began exploring alternatives to traditional officebased interventions. IN traveled with the victim advocate to visit new referrals at home instead of scheduling appointments at the center. In contrast to her earlier experiences with office-based interventions, she was warmly welcomed into the women's homes; the women quickly established an emotional connection and became invested in counseling. Many women continued counseling beyond one or two visits, which had never occurred in an office-based format. Although home visits were appreciated by most of the women, a few clients refused home visits. Most of these women were living with their partners at the time. Consequently, home visits could be dangerous for them if discovered by the husband. On one occasion the husband came home during the home visit. In this case, the wife had warned us of his imminent return but did not want us to leave. After this home visit, the wife refused any further visits or participation in individual counseling or groups; we suspected her refusal was likely due to her husband's reaction to our presence in the home. This was an important lesson in the potential risks to the women if the batterer was aware of the home visits. After the success of the home visits, we invited the women who were participating in the home visits to attend a weekly domestic violence group. We began meeting with the women over a pot luck dinner, creating an informal atmosphere for sharing problems and concerns. Initially, the women did not interact directly with one another. Sharing an experience or problem would be followed by long periods of silence; the speaker's comments would elicit no verbal response from the other women. As they became comfortable with the group, the participants began to respond to each other with mutual advice and support. The success of this group appeared to be due to establishing an alliance with the women through home visits, the informal atmosphere for discussion that did not over-emphasize didactic teaching, as well as including traditions such as the sharing of meals. In 1992 the medical clinic and social service program closed second-

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ary to loss of funding. Prior to this the mental health program also had closed. Medical clinic staff had served as a support network by sharing information and being available as a resource for clients. IN experienced increasing isolation and burnout as the domestic violence program expanded and the support services disappeared. She left the domestic violence program having directly counseled 25 women, the majority in her last six months of consultation. The specific characteristics of the women are reported elsewhere (Norton & Manson, 1995). DISCUSSION Much has been written about the provision of culturally sensitive counseling to American Indians (Attneave, 1985; Manson, Walker & Kivlahan, 1987; Trimble & Fleming, 1989), but little is known about how these concepts should be applied in domestic violence interventions. This paper attempts to bridge this gap between our present understanding of mental health counseling among American Indians and the need for domestic violence intervention in American Indian communities. An important reason for bridging this gap is that American Indians will often not utilize services designed for Anglo-Americans. Sue, Allen and Conway (1978) found that American Indians were more likely to terminate after the initial contact compared to Anglos. This point was illustrated by IN's experience with office-based visits; home visits resulted in many fewer cases terminating after initial contact. Katz (1981) described the office as formidable and alien to Indian youth, and used the car as a more familiar environment within which to engage these young people in therapy. In a similar vein, Indian women feel more comfortable in their homes than in an office setting. Interviewed at home, the women responded more openly and were receptive to counseling. Flexibility is needed in order to provide home visits, and was an effective means of building trust in the counselor. According to a review by Trimble and Fleming (1989), flexibility and trust are the most important characteristics of the counselor-Indian client relationship. Trust is valued in those who serve a healing role, and also is an important characteristic of counselors, related in no small measure to the historical abuses of Indian people which include broken treaties, forced relocation to reservations, and the removal of children from their families to boarding schools and foster care (Everest, Proctor, & Cartmell, 1983; LaFromboise & Dixon, 1981).


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Group therapy is the treatment of choice in many American Indian communities and is also a popular intervention among many nonIndian domestic violence programs (Edwards & Edwards, 1984). The success of this group format often hinges on the incorporation of important Indian traditions and values such as sharing (Katz, 1981). Sharing food at the beginning of each group facilitated the sharing of problems and concerns. Problems were shared as the women talked in uninterrupted, narrative. This duologue where group members pay little attention to each other was described earlier by McDonald (1975), and is reminiscent of a traditional healing practice, the Talking Circle. In a Talking Circle the leader begins by sharing his or her feelings with everyone in the circle, but to no one specifically. The participants do not reply directly to the remarks of any person in the circle, and speak as long as they desire without interruption or contradiction (Manson et al., 1987). Despite the tendency to speak in this particular narrative form, as they became more comfortable with the format, the women began to interact more pointedly to individuals and to provide support for each other. Although the domestic violence group was well received by many of the women, others who refused to participate in the group or did not want counseling from the victim advocate expressed concerns about confidentiality. On reservations clients fear their problems will be broadcast along the "tribal telegraph" (Anderson & Ellis, 1988). These fears also existed in this urban setting, where clients were afraid that their problems would be talked about in the local urban Indian community. Although the women who participated in the domestic violence program were from many tribes, we have tended to examine the common experience of these American Indian women instead of highlighting intertribal differences, which would be difficult to determine because of the small numbers from many tribes. There is some justification for designing interventions for urban American Indians in general; Trimble and Fleming (1989) describe an urban Indian typology that is characterized by the internalization of pan-Indian values. Yet it is important to recognize that there may be intertribal variation; for example, DeBruyn et al. (1990) describe a Keresan woman from a Rio Grande Pueblo in the Southwest who went to a shelter for battered women. She was told if she did not return home, she would be under house arrest in the pueblo for the rest of her life, and her children could not join her. In the Rio Grande pueblos, under the influence of the Catholic church, a woman is expected to stay with her husband, particularly if

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he is from the same pueblo. In contrast, shelters for battered women are active on several reservations including Southwest and Northern Plains communities. The loss of the medical clinic was a major blow to the continuing success of this program, since the nurse practitioner in the medical clinic referred the majority of the women. Attneave notes the varying success of urban American Indian programs since the 1970's, which depends on the ability of the program to compete for funding and the goodwill of local professionals (Attneave, 1985). The lack of program stability also contributed to burnout, such as when the support network of the medical clinic and other services at the health center disappeared. The instability of programs in urban Indian health centers is a major barrier to the provision of services to American Indian communities. A final point is that the interventions described here are not only relevant to urban American Indian communities, but may also be applicable to women who are uncomfortable participating in traditional office-based models of counseling: a concern for many women from other ethnic and poor communities. SUMMARY We participated in and have described a domestic violence intervention program that was responsive to the needs of this urban American Indian community. Although there is no outcome data from this program, our experience suggests that these women experienced a reduction in their distress. We were able to reach clients who otherwise would not use non-Indian services, and who were not comfortable with an office-based approach. Many of these women were able to build a relationship with the counselor, and benefit from active participation in a domestic violence program. Home visits involve additional time and effort, but relative to the alternative of underutilization of officebased interventions, home visits significantly enhance care and the effectiveness of counseling. REFERENCES Anderson, M.J. & Ellis, R. (1988) On the Reservation. In N.A. Vacc, J. Wittmer & S.B. DeVaney (eds.) Experiencing and Counseling Multicultural and Diverse Populations. Indiana: Accelerated Development.


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Attneave, C.L. (1985) Practical Counseling With American Indian and Alaska Native Clients. In P. Pederson (ed.) Handbook of Cross-cultural Counseling and Therapy. Connecticut: Greenwood Press. Debruyn, L., Wilkins, B. & Artichoker, K. (1990) It's Not Cultural: Violence Against Native American Women. Paper presented at the 89th American Anthropological Association Meeting. Edwards, E.D. & Edwards, M.E. (1984) Group Work Practice With American Indians. Social Work With Groups, 7, 7-21. Everett, F., Proctor, N. & Cartmell, B. (1983) Providing Psychological Services to American Indian Children and Families. Professional Psychology: Research and Practice, 14, 588-603. Indian Health Service (1991) Indian Women's Health Care Consensus Statement. Washington, DC: Office of Planning, Evaluation and Legislation. Katz, P. (1981) Psychotherapy With Native Adolescents. Canadian Journal of Psychiatry, 26, 455-459. LaFromboise, T.D. & Dixon, D.N. (1981) American Indian Perception of Trustworthiness in a Counseling Interview. Journal of Counseling Psychology, 28, 135-139. Manson, S.M., Walker, R.D. & Kivlahan, D.R. (1987) Psychiatric Assessment and Treatment of American Indians and Alaska Natives. Hospital and Community Psychiatry, 38, 165-173. McDonald, T. (1975) Group Psychotherapy With Native-American Women. International Journal of Group Psychotherapy, 25, 410-420. Norton, I.N. & Manson, S.M. (1995) A Silent Minority: Battered American Indian Women. Journal of Family Violence, 10(3), 307-318. Sue, S., Allen, D.B. & Conaway, L. (1978) The Responsiveness and Equality of Mental Health Care to Chicanos and Native Americans. American Journal of Community Psychology, 6, 137-146. Trimble, J.E. & Fleming, C.M. (1989) Providing Counseling Services for Native American Indians: Client, Counselor, and Community Characteristics. In P.B.Pederson, J.G.Draguns, W.J. Lonner & J.E. Trimble (eds.) Counseling Across Cultures. Honolulu: University of Hawaii Press. U.S. Congress, Office of Technology Assessment (1986) Indian Health Care. OTA-H-290. Washington, DC: US Government Printing Office. U.S. Department of Commerce, Bureau of the Census (1991) Race and Hispanic Origin. 1990 Census Profile, Profile #2. Washington, DC: US Government Printing Office.