“She said if I don’t take the pills, she can have me locked up on a psych ward. Can she do that?”
The question came from a 14-year-old Native American girl* standing just inside my open office door. She didn’t say ‘hello’ but only knocked on the door frame, pointing back down the hall with an angry look on her face, and blurting out her question at me.
I knew her pretty well; we had good rapport from a talking circle she’d participated in several months earlier. She’d ended up in foster care about three years earlier after her mother was charged with child neglect by state authorities. Up until then, there was not enough food for her and her little sisters in the condemned house they inhabited without running water or heat. But at least they’d been a family, and that was the loss she felt most.
Her elderly grandmother was willing to take in her sisters but didn’t feel she could handle her ‘acting out’ teenage granddaughter, no matter how much she loved her. She’d been apprehended recently after running away from her fourth foster care placement. She’d left that family of total strangers in the middle of the night and walked thirteen miles before getting picked up by tribal police. She told me she was scared of the men she was living with and desperately longed to see her sisters.
There she stood holding a prescription form for psychiatric medication she’d just received from the Indian Health Service psychiatric nurse down the hall. She’d been compelled to see this nurse as a condition of her ‘probation’ terms as set by the tribal children’s court. It seemed ludicrous to me that she’d be placed on ‘probation’ for a status offense like running away, but the tribe had its own code of law and order, and obedience toward caretakers was written right into the juvenile section. The state caseworker had successfully pressed the issue, and the judge complied.
I think I felt honored to receive this impromptu, point-blank question from such a fierce spirit. I know I also felt politically vulnerable trying to answer her while standing out in the open hallway of an Indian Health Service clinic. The issue as to whether she had freedom to choose what substances she put in her body was actually pretty complicated.
She trusted me enough to ask, so I ushered her inside. Our conversation went something like this:
“Can she make me take them? Yes or no, Walker?”
Calling me by my last name was her way of acknowledging and respecting me. She never called me ‘doctor.’
“She could make a lot of trouble for you,” I told her as she sat down next to my desk. “She could say you were going against her medical advice. She’s got a lot of power.”
“But could she have me locked up?”
“Seems like it would take a lot of energy and time to go that far.”
She sighed. “My auntie says I don’t have to take them if I don’t want.”
“Then I guess you don’t have to.”
“My auntie’s not my guardian, the state is. The judge says I have to do what that nurse says. She says she’ll have me locked up if I don’t take the pills.”
“How would she know if you didn’t? Are you supposed to have lab work done to show you’re taking them?”
“No. She said she can check the pharmacy on her computer and see whether I get refills. I have to keep appointments with her about it all too.”
She looked at me solemnly and waited. I was expected to offer advice.
“Maybe go ahead and get the refill every month and keep the appointments with her until you’re off probation. That doesn’t mean you have to really take them.”
“Just flush them down the toilet?” She smiled slightly at me.
“I didn’t tell you to do that,” I answered while nodding affirmatively.
“I don’t want to take them. I told her but she said I had to. She says I’m depressed and don’t know it.”
I thought about that. “Well, I can’t imagine the things you shared in circle haven’t brought you down at times.”
She shrugged. “I’m usually more pissed off than anything else. How’d you like to get cuffed and locked up just for trying to visit your family?”
I shook my head sympathetically. She got up to leave but looked at me and hesitated.
“Are you going to tell her I’m not complying?”
“Are you going to write down any of what we talked about?”
A sly smile crossed her face. “Will you get in trouble?”
“Not if I’m careful,” I answered. “So don’t you tell anybody either . . .”
“Not even my auntie?”
I shook my head. “We never met. We never had this discussion. Better go catch up with your social worker before she comes looking for you.”
An expression of delight crossed her face. We had an agreement. We’d become collaborators in a covert operation that allowed her to make her own choices.
“I’ll bet you get in deep shit anyway,” she laughed as she flung my office door open to leave before glancing back at me.
“Because you’re acting-out,” she laughed.
Coercive situations like the one I’ve depicted subtly replicate older times when colonizers dominated Indian people using guns and ammo. In contemporary times, oppressive mental health systems of colonizers use pills and labels to force-feed ‘civilizing’ principles. This intergenerational comparison might seem more intriguing if you consider that the psychiatric nurse in question was a Commissioned Corps officer in full uniform blues while meeting with this girl in the bunker-like Indian Health Service (IHS) clinic located along “Fort Road.” If you drive straight out along that road for 23 miles, you’ll end up on the park grounds of the actual historic fort where this girl’s ancestors were once bull-whipped for non-compliance.
I actually do love being a psychologist (for the most part), but I don’t go in for trying to dominate or control people, especially strong-hearted 14-year-old girls. I tend to admire native kids with the audacity to bang on a pashtin’s (white man’s) office door and demand immediate information. Moments like that help me feel that I’m doing my job. The gift of her story with the nurse only fortified my own motivation to begin intellectual inquiry into the everyday subtleties of the psychology of intergenerational perpetration and resistance to oppression. Although she might not know what I mean by all that gibberish, I’m positive she sensed very clearly that I wanted to know about just these kinds of events, and that her successful transcendence of such situations was one of my own major hopes for her and kids like her.
As I’ve mentioned in prior posts, the IHS is dominated itself by a biopsychiatric perspective. When I took issue with this view during a fractious meeting on the notorious afternoon of September 11, 2001, I was assertively informed by a Commissioned Corps psychiatric nurse that “Indian Health Service has always and always will use the medical model in provision of mental health services.” I was also told by another psychiatric nurse who was present that I was “the greatest threat to children ever seen on this reservation” due to my failure to accept his view that Indian children had the ‘brain disease’ of ‘ADHD.’
That’s all along time ago, but the difficult experience set me on a wonderful journey. I already knew then that I wanted to be a ‘community psychologist’ working with oppression (external and internal, its perpetration and its suffering) and allying myself with whatever ‘interventions’ increased empowerment and liberation and undermined systemic indoctrination, racism, and injustice. Noble ideals—but from that point forward, I entered the harder work of becoming one. I was neither unique nor alone in adopting that stance, but the ‘covertness’ through which I interacted with like-minded others while I was with IHS played out much like a spy novel.
Establish who your trusted contacts are and be sure. Don’t share your non-psychiatric, community-oriented views over email or the phone. Meet off-site or in the field to discuss any plans toward getting around the status quo. Don’t differ with Commissioned Corps officers—they’re power lies in their rank, not their role, and a civil service psychologist will always be a subordinate to a Commissioned Corps anybody. Many of these officers are trapped working on ‘twenty years and out’ and can’t make waves for sake of their career. Don’t expect them to jump on board with radical, community-based ideas. As to the social worker with eight months until retirement, no clientele or specific duties, and his feet up on the desk reading the Grisham novel, don’t tell him about your secret efforts to partner with native people either. He’ll only say “rots of ruck” and spill the beans to the medical director that you’ve ‘left the fort and joined the savages.’
I’m sure similar resistance and counter-resistance still occurs in Indian Health Service as may be witnessed in the 2012 case of Lieutenant Commander Michael Tilus1 who dared go public when he couldn’t get anyone in the Spirit Lake tribal community, or in the state of North Dakota, or in the entire U.S. Public Health Service to step up and protect abused Indian children from being sent back to live with their abusers. Hmm, sorry to notice but that kind of thing seems to have happened across Indian Country many times over many years. I do commend Commander Tilus for his effort, but I’m not sure he realized what a lonesome stand he was taking against a powerful legacy of horizontal violence. No good deed goes unpunished and, to mix my metaphor, the messenger was the first to go.
Commander Tilus seems to have been coaxed back into the fold with an apology from the IHS director. But I hope he continues to honor and nurture his inner rebel. Unfortunately, he appears to have maintained the idea that one of the best things psychologists can offer indigenous communities dealing with oppression’s bitter fruits is to get trained so they can prescribe medications. Two divisions of the American Psychological Association (Div. 18- Psychologists in Public Service, and Div. 55-American Society for the Advancement of Pharmacotherapy) have decided to support this same fiction of a solution2.
Thus, the Indian Health Service medicine dance continues with biopsychiatry deciding who gets to enter their circle. There have been recent signs of a possible break in this generational cycle between oppression, reaction, indoctrination, sedation, and more oppression. Read, for example, the hopeful signs for a community-oriented and empowering viewpoint embedded in strategy “III.B.2.” of the Indian Health Service’s American Indian/Alaska Native National Behavioral Health Strategic Plan 2011-2015:
Recognize the heavy influence of biomedical models in IHS as well as the need for more integrated care by creating a track within the various IHS health conferences and meetings that addresses behavioral health and integrated care.3
Sadly, this glimmer of organizational self-reflection is followed immediately by strategy III.B.3.
Assist the Indian Health System to make needed prescribed psychotropic medications available to persons served.3
To be fair, the Indian Health Service faces an enormous hurdle before it can ever begin to ally with the healing spirit still alive and resilient in so many indigenous communities: It must shed its drug addiction and obtain sobriety.
Just as it’s impossible to help someone see their addiction while they’re really stoned, so is it impossible for an agency to help people with their problems in living while that agency is totally drug dependent. Only from a state of sobriety would this agency begin understand its own place and role in native experience from the community psychology perspective.
Tragically, the Indian Health Service is lost in a sustained binge pattern. I’ll stop here but will offer a more detailed substance abuse assessment for IHS in a future blog.
* * * * *
1 Memoranda pertaining to CMDR Michael Tilus, U.S. Public Health Service, Commissioned Corps, Indian Health Service, 2012
2 Prescriptive authority in Indian County, APA Monitor, 2010, 41, 2,
3 American Indian/Alaska Native National Behavioral Health Strategic Plan 2011-2015, Indian Health Service,
*Features of this story have been significantly altered in order to protect confidentiality
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.