Chapter 19. Occupational therapy with Native American youth

Maggie Heyman-Hotch

When developing a new occupational therapy programme where there have not been services in the past, it is essential for the therapist conducting a needs assessment to remain open to the many voices and opinions of everyone one may encounter. This includes the key stakeholders in the system itself, the administrators who inform policy and will make decisions and, most importantly, those who will receive direct services (see Ch. 1). When completing my capstone Master’s project at Pacific University, I developed and piloted an occupational therapy programme at a federally operated boarding school for Native American high-school students. In reflecting on the development and subsequent evolution of this programme in the past 6 years, the concepts of occupational justice (Townsend & Wilcock 2004), occupational apartheid (Kronenberg & Pollard 2005; see Ch. 4) and occupational deprivation (Whiteford 2004) have applied on many levels. While it is not within the scope of this chapter adequately to explore the historical background for the current occupational situation of Native American youth both on and off reservations in the USA, I hope to tell the story of the youth that I have worked with as a means to illustrate the possibilities of occupational therapy to address the occupational needs of Native youth in the USA.

During the needs assessment process it became apparent to me that the occupational challenges of the students in Native boarding schools could not be considered in isolation. If occupational therapy services were to be effective for these students, it seemed that a programme truly holistic in nature must be designed to address the whole picture of the student beyond what traditional school systems provide. My undergraduate studies in anthropology had helped me understand that to do so would be to honour traditional Native philosophies of health and wellness. To accomplish this, interventions were designed that attempted to address the ‘whole student’ in context. This context included the occupational demands of the school environment, the effect and current influence of the students’ home environment, the previous occupational experience of each student and the historical trauma of Native people both within and outside the boarding-school environment. In addition, the students quickly taught me that the sociopolitical environment of each student’s particular tribe is also relevant to their occupational experiences.

For all students, the developmental stage of adolescence as it relates to their ability to develop their own personal identity is a critical time. For these students, the boarding-school environment provides a unique opportunity for this developmental task. Native youth from as many as 60 to 100 tribes in any given school year participate in occupations together that can help them collectively define their identities. For many, it presents the choice of different, healthier occupations than those engaged in on the reservation (i.e. gang activity, vandalism (starting fires, throwing rocks at cars, windows, etc., graffiti) and violence among youth, which appeared to be primarily the result of boredom, or occupational deprivation).

To provide occupational therapy services that are consistent with the philosophy of the profession in an occupation-based, client-centred manner seemed an opportunity to empower the students to connect the elements of their lives that had led to their boarding-school attendance in a manner that could help them find balance in their high-school experience. It was my hope that, if they could learn to experience balance and wellness at this high school, they could translate those skills to build a fulfilling and productive future of their choosing.

I started by conducting a needs assessment and developing a business plan that described in detail the ways that occupational therapy could holistically address the needs of the individual students and the school system as a whole. As a result, a full-time occupational therapist position was created using the school’s existing federal funds. Initially the position was for half-time special-education-related services in accordance with the Individuals with Disabilities Education Act of 1997, which was reauthorized by Congress in 2004. The other half of my time was to provide transition services in the regular education programme aimed at helping students attend college or become gainfully employed. The focus in both programmes was on enabling students to pursue higher education through developing the skills sufficient to meet occupational performance demands.

The programme has since evolved as the needs of the students and the system have changed. Despite many changes I most highly value and appreciate the freedom that comes with developing an emerging practice programme where the occupational therapy services were not predetermined by what had traditionally been done in schools. I have been able to make sure that the role of the occupational therapist evolved to remain holistic in practice and demonstrate the contention that ‘most people whose access to and engagement in meaningful occupation is at risk could benefit from occupational therapy services’. My experience in providing services to this population as teenagers and the obvious lack of services for these children in their younger years through the Indian Health Service and the federal and public schools systems supports many of the concepts presented by Kronenberg and colleagues in the book Occupational Therapy Without Borders (2005), in particular the contention that people who have experienced occupational apartheid or injustice are not in a position to seek the services of occupational therapists even if they have a referral.

The stories that follow will attempt to demonstrate how an emerging practice occupational therapy programme can holistically address the needs of Native students even in the traditional confines of a federally operated boarding school. Wherever possible the stories of the young people told in this chapter are the result of interviews and are told with permission from the individual, and in their own words to the closest extent possible. Identifying details have been removed for all students to reduce the effect of potential stigmatization of the young people through their participation in the programme.

Zac

The first story is that of a young man I met during my first year as an occupational therapist: a 16-year-old junior student struggling to stay in school at the boarding school. This young man, whom we will call Zac, came from a Plains tribe and had many challenges facing him. The son of an alcoholic mother, whom he was often required to care for while at home, he also had a significant cognitive deficit, dyslexia, and a drinking problem caused by several bouts of depression. School was very difficult for him even in modified classes, but he was successful socially and had many friends on campus. Zac was well liked by his peers but encountered difficulty in the dormitories with doing required chores such as cleaning, and hourly ‘check-in’ with dorm staff. He often got into confrontations with his dorm staff and was frequently written-up for violations related to his disability: he was unable to sequence the assigned tasks properly or remember to complete them. Zac hated to be in trouble and would get depressed when written-up, which usually caused him to leave the campus to drink, which often got him into more trouble.

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