The Full Story
Are Statistics in Clinical Psychology Giving us the Whole Picture or is There Something More?
Alita was a 27-year old Native American Indian undergraduate student when she decided to seek help at her university counseling center. She had just transferred to the university from a tribal community college and it was affecting her more than she thought it would. Alita was experiencing fatigue, poor concentration and failing to complete many of her assignments. All of this had her questioning whether or not she belonged there because she could not “seem to get things done as quickly as other students”. When told by her professors to schedule meetings with them, she hesitated because she thought they would confirm her fears of not belonging.
On top of this she was feeling like her life was “out of control”, was relying too heavily on alcohol, and had no one to turn to since both her parents had passed away and she was taken from the reservation she had lived on as a child at the age of 10 and put in foster care. She felt like she was expected to act “White” once placed in the foster care system and subsequently struggled with her identity, feeling stuck between her Native American Indian roots and a White middle-class lifestyle but never truly fitting in anywhere. In the foster care system she was always told to not “act like one of them” (presumably Indian) and other Indians accused her of being an “apple: red on the outside, white on the inside”.
Alita currently wanted to explore the missing parts of her cultural belief system since, despite being taken away from the reservation at a young age, her culture continued to be a part of her everyday life. She wanted to reclaim her identity and find a place in the Native American Indian community and allow it to play a part in her healing process (Simms).
Alita is not the only one.
Roughly 4.2 million Americans identify themselves as having Native American or Alaska Native heritage and about one-third live on reservations.
Of those 4.2 million, over 19% reported having a mental illness in the past year (Native).
Native peoples in America are 2.5 times more likely to report experiencing psychological distress than the general population over a month’s time.
Compared to the total U.S. population, nearly twice as many Native people live in poverty.
These statistics from Mental Health America, who is the nation’s leading community-based non-profit dedicated to addressing mental health (Native), undoubtedly provides us with important information. Statistics are great, but are they telling the full story? What do these numbers really mean?
They mean that the mental health system is failing Native/Indigenous peoples. Why and how mental illness develops varies greatly among Native peoples. Further, in the Native American tradition, the spirit is inextricably linked to healing in a way that contrasts with the mechanistic, western scientific approach that is prominent in the mental health field today.
This Western approach is characterized by its emphasis on empirically supported treatments (ESTs) which are specific psychological treatments that have been proven to be empirically valid in a controlled research experiment. According to Gianluca Castelnuovo who has a Ph.D. in clinical psychology and is both a researcher and professor in the field, ESTs have gained power and credibility in the field of psychology due to economic and professional forces. For example, The National Institute of Mental Health (NIMH), which is a significant source of financial support for psychotherapy research, applies the pharmaceutical model for research to evaluate psychotherapy treatments (Castelnuovo). This means that randomized controlled trials (RCTs) are used which are when participants are randomly placed in either an experimental (treatment) group or a control group.
Clinical psychologist Richard McFall, who is now retired from teaching at Indiana University, argues for the field to adopt a Manifesto consisting of a Cardinal Principle and two corollaries. The Cardinal Principle is that scientific clinical psychology is the only legitimate form of clinical psychology. He places an emphasis on the idea that clinicians must ensure that their practice is scientifically valid. To McFall and those with similar perspectives, the only form of legitimate clinical psychology is practiced by scientists and held accountable to the rigorous standards of scientific evidence.
The first corollary is that psychological services should not be administered to the public until their exact nature has been clearly described, their claimed benefits have been stated explicitly and scientifically validated, and possible negative side effects that may outweigh benefits have been ruled out empirically.
The second corollary is that the primary objective of doctoral programs in clinical psychology must be to produce the most competent clinical scientists. He believes that the focus should be on training all students to think and function as scientists in every aspect and setting of their professional lives (McFall). While McFall does not forbid invalidated or unproven clinical services from being implemented with the public, he emphasizes that clinical work shouldn’t be implemented without empirical support unless it is done so under controlled, experimental conditions, such as in a RCT.
Why is this pharmaceutical model that emphasizes ESTs (and RCTs) which McFall argues is the only legitimate form of clinical psychology so problematic? It doesn’t account for possible confounding variables that threaten causal influence, such as talking with an expert who offers hope, support and empathy.
Additionally, the use of RCTs means that there is a tradeoff of external validity in favor of internal validity; the emphasis is on really sound, well-controlled designs with stringent inclusion criteria and brief experimental time tables as opposed to the effectiveness of the treatment in the real world for the general population who do not adhere to such strict criteria and who have ebbs and flows in their mental health over time. This is a problem because then treatments aren’t being tested on people who are representative of the people who will then be receiving the treatment outside of experimental conditions on a variety of levels whether it be age, ethnicity, cultural affiliations, etc. New effects and different results could pop up that could therefore affect the effectiveness of the treatment.
An approach to psychotherapy that addresses these concerns is evidence-based practice (EBP). Instead of being solely based on best research practices or outcomes directly from ESTs, EBP integrates a clinician’s experiences, a patient’s values, and best research practices (ESTs) to make clinical decisions. EBP takes into account the complexities and challenges of conducting a research study and how those factors can impact the true effectiveness of a psychotherapy treatment. In the real world, clients and clinicians bring variables to the table that can impact the effectiveness of a treatment, and those variables need to be taken into account in order to make the decisions that will hopefully be the most effective for the client.
One of the limitations of the pharmaceutical model for psychotherapy and McFall’s Manifesto lies in the reality that they stem from a colonial perspective on research by seemingly not accounting for different cultural values, such as Native/Indigenous beliefs and practices. Every culture and group has its own ways of knowing and practicing that knowledge. So, it is problematic to subscribe to an approach to psychotherapy that places emphasis on only evidence-based models being acceptable and does not take into account different cultural contexts. For example, according to Dr. Glen McCabe a member of the Aboriginal community and of the Faculty of Education at the University of Manitoba , the Indigenous ways of knowing emphasize how healing involves the mind, body, emotions and spirit.
However, I am not saying to apply Indigenous knowledge and beliefs to all patients. To this point, Dr. Robin LaDue, a clinical psychologist who has lectured worldwide on mental health treatment in Native American communities, strongly recommends that non-Indian counselors abstain from participating in and using Native American practices. Doing so could “condone the stealing and appropriation of Indian and Native spiritual activities and practices” that are part of a culture that has its own practitioners in their respective communities, such as healers and elders. Implementing such practices without the consent of Indigenous healers also shows disrespect for their origins and contexts (LaDue).
The therapist-client relationship is built on trust, honesty, and respect and exploiting Native practices will compromise this and efforts to establish a solid relationship with not only the client, but also the Native community. The relationship between non-Native therapists and the Native community needs to be based on a foundation of collaboration and respect for the community and their practices, as historically these communities have been undermined and shrugged off as believing in “mumbo-jumbo”(McCabe).
Having said this, it is very important as a counselor to gain cultural competence in not only Native ways of knowing, but other cultures as well. To do this, counselors have to actively work toward achieving such competence and also be willing to address their own biases and work to confront them in a way so that they will not impact their treatment of others. Such knowledge can affect the effectiveness of a treatment and can also impact clinical decisions on what treatment is administered in order to account for such cultural factors.
In the case study of Alita, a blended counseling approach was used by her counselor, Dr. Winona F. Simms, PhD, a Muskogee (Creek) and Euchee practitioner, student advocate, and educator in the Native American community, that combined an “integrated relational behavioral-cognitive strategy with traditional healing approaches, including practices such as talking circles, sweats, and participation in cultural forums in order to confront her struggles with cultural identity, self-confidence, and academics”(Simms). Alita’s case demonstrates how someone’s problems may not be resolved if they are approached with a more conventional counseling technique compared to an integrated treatment plan that takes into account factors unique to the patient such as culture, spirituality and values.
This is why empirically supported treatments (ESTs) are not the only viable option and should not automatically be administered to all clients who present with certain symptoms or diagnoses.
Further, an EST is not an evidence-based practice (EBP), but only a component of it. There are many confounding variables that present outside of controlled conditions that can impact the effectiveness of a treatment, from a clinician’s area of expertise to a patient’s motivation and accessibility to treatment to a patient’s spirituality. Practitioners need to take into account patient values as well as clinician experience in order to devise and carry out the most effective treatment plan possible.
This not only applies to Native/Indigenous cultures, but any culture or group of people. We all want to feel seen and heard, especially when it comes to mental health, and EBP is a step toward doing that.
Those of us in and outside of the field of clinical psychology need to push ourselves to dig deeper and expand our minds from this strict focus on empirical support and statistics to a more inclusive view that takes into account patient values, beliefs, and cultural practices, whatever they may be. This perspective is not only important in psychology, but life in general as a step toward a more culturally competent society.
Statistics don’t always tell the full story, so why should we base all our decisions solely on them?
Works Cited
Abstract drawing of a brain. https://www.american.edu/cas/psychology/ma/.
Castelnuovo G. (2010). Empirically supported treatments in psychotherapy: towards an evidence-based or evidence-biased psychology in clinical settings?. Frontiers in psychology, 1, 27. https://doi.org/10.3389/fpsyg.2010.00027
Image of a pouch of tobacco. (2011). The American Legion. https://www.legion.org/magazine/94878/sacred-tobacco.
Image of a sweat lodge. (2016). Global Volunteers. https://globalvolunteers.org/blackfeet-cultural-experience/.
Image of Medicine Wheel. Granddaughter Crow. https://www.granddaughtercrow.com/native-american-medicine-wheel.html.
LaDue, R. A. (1994). Coyote returns: Twenty sweats does not an Indian expert make. Women & Therapy, 15(1), 93–111.
McCabe G. (2008). Mind, body, emotions and spirit: reaching to the ancestors for healing. Counselling Psychology Quarterly, 21(2), 143–152.
McFall, R. (1991). Manifesto for a science of clinical psychology. The Clinical Psychologist, 44(6), 75–88.
Native and indigenous communities and mental health. https://www.mhanational.org/issues/native-and-indigenous-communities-and-mental-health.
Simms, W. (1999). The Native American Indian client: A tale of two cultures. In Y. Jenkins (Ed.), Diversity in college settings: Directives for helping professionals (pp. 21–35). New York: Routledge.
Venn diagram of components of EBP. (2020). https://www.library.ucdavis.edu/guide/ebp-resources/ebm-ebp-venn-diagram_01/.
Visual representation of statistics. Mental Health America. https://www.mhanational.org/issues/native-and-indigenous-communities-and-mental-health.
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