Q&A With Justin Douglas (Doug) McDonald, Professor of Clinical Psychology at the University of North Dakota (UND) and Director of the school’s Indians Into Psychology Doctoral Education (INPSYDE) program

By Alex McEllistrem-Evenson, Editor, Health Workforce News

Recruiting and retaining mental health professionals who are not only willing to serve Native American populations but who are also qualified to do so, from a cultural perspective, is a top priority and a unique challenge. In 1992, the federal government authorized funding for the American Indians into Psychology Program (INPSYC). Administered through the Indian Health Service (IHS), INPSYC “provides scholarships to graduate and undergraduate students pursuing psychology degrees, and furnishes in-the-field training opportunities in Indian communities to graduate students in clinical psychology.” Currently, INPSYC programs are funded at Oklahoma State University, The University of Montana, and The University of North Dakota.

HWIC recently spoke with Justin (Doug) McDonald, Ph.D., Professor of Clinical Psychology at the University of North Dakota (UND) and Director of the school’s Indians Into Psychology Doctoral Education (INPSYDE) program, a variation of the INSPYCH program focusing specifically on graduate students. McDonald specializes in cross-cultural psychology relevant to the assessment and treatment of Native Americans and has directed the INPSYDE program at UND since its inception.

Please tell us about the INPSYDE program.

When you compare the representation of ethnic minority psychologists within the profession, the ratio is smallest for American Indians than it is for any ethnic group, certainly including the majority culture. The INPSYDE program primarily exists to try and train as many American Indian psychologists as we can with an eye toward recruiting students that are interested in returning and working with their own people.

Since the program’s inception in 1992, we’ve conferred 14 doctoral degrees and over 25 masters degrees. Most of those students are still in the program, of course. Around 25 to 30 percent of the students in our clinical psychology graduate program have been Native at any given time, which is pretty remarkable.

Historically speaking, has the INPSYDE program been well-funded?

The funding actually increased five years ago. It has been ongoing, we’ve been funded every year since 1996. We got an increase from $200,000 to $250,000 about five years ago and it’s remained constant since then.

As the originator and director of this program since 1992, I can’t say enough about the support I’ve gotten at every level: my own psychology department here at UND, the clinical psychology department, UND as a whole, and IHS. The support has been phenomenal. We couldn’t have done it and had the kind of success that we’ve had without the kind of support that we’ve had.

INPSYDE and similar programs focus on increasing cultural competence within health professions. Why is this important and what are the particular challenges of providing cross-cultural training within a mainstream psychology curriculum?

Think of competence in the larger sense: in terms of mental health care delivery, everybody would like to think that whomever they’re going to see is “competent” in terms of the specific area that the person might have a problem – depression or anxiety or what have you . That issue is taken extremely seriously by the American Psychological Association in their accreditation of psychology programs across the country; they’re training folks that are more competent to be able to work with people when they get out. The one thing, however, that has been overlooked in psychology for many, many years is cultural competence for folks that are going to be competent to work with people from different cultures.

A lot of this has to do with the fact that the types of students who were winding up getting recruited into APA-accredited programs for many years were not students of color, frankly. They were middle-to-upper class, white students who came from better schools, had high GPAs and GRE scores, and probably even had computers in their high schools. When you think about it, whether it’s elementary school or high school, the quality of textbooks or learning materials, the teachers, and everything else is in direct proportion to how much money the school has. That’s a question of the tax base that surrounds the district that the school is in. Aside from BIA [Bureau of Indian Affairs] schools which there’s not that many of anymore, what do you get with schools located in reservations that have unemployment rates of 50 percent and essentially no tax base?

They’re scrambling just to teach anything in many of these schools, and it’s not hard to understand why many Native students get to college and are underprepared and “underperform” when put up alongside their middle-to-upper class, white, majority-culture peers. Those Native students were not getting into psychology even though there were programs like ours that had proven that these students were fully capable of handling the graduate program and achieving the Ph.D. Essentially, they weren’t given the chance because of the criteria and the process of selection.

One of the problem areas that the INPSYDE program seeks to address has to do with the “substandard quality” of mental health services within Native American communities. What causes these quality-of-care issues?

It’s complicated, that’s the main thing to understand. When you start peeling back the layers and start looking at the variables of why there’s been a lack of quality mental health care on our reservations in the past, it’s extremely complicated and the issues are historical. They have to do with the communities themselves, they have to do with what on a larger scale happened to our Northern Plains tribes traditionally. We teach entire classes on this.

A lot of it also has to do with access and policy. In our five-state area [ND, SD, MN, MT, WY], the vast majority of mental health care that’s being provided is being provided by Indian Health Services; traditionally, IHS mental health is completely underfunded, and so you can’t blame IHS service units for the fact that they can’t recruit top-quality mental health care professionals. They just flat-out don’t have the money and they’re geographically and culturally isolated, spread out across different areas of our states.

In terms of quality-of-care, the cultural competence issue comes up again. It doesn’t matter if you have somebody that was trained in Harvard, if they’re out there but they don’t understand and don’t share or comprehend the particular worldview of the Native populations they serve, then they’re not going to be competent. They may be really smart, they may have graduated from a great university, but that does not guarantee that they are cross-culturally competent. Most likely, they’re going to have a hard time delivering quality services because they won’t be accepted in the community.

There’s a large number of variables that work against being able to recruit top-quality, top-flight psychologists to deliver high-quality mental health care. Our idea with INPSYDE is to try and recruit potential students from these high-need areas that will ultimately become psychologists and want to go back to those areas.

Stigma is another issue impacting access to mental health services, particularly in rural areas. Are stigma issues any different with Native American populations?

I don’t think it’s much different. I think in a lot of cases it’s more of a rural vs. urban phenomenon there. I will say, however, that it is complicated by the fact that many more traditional Native American folks still hold a priority value for more traditional medicine men and women. So there you have this dichotomy, a confusing situation: “I’m in distress, I’m hurting, I need some help, but where do I go? Do I go to the Western-oriented hospital and seek out someone with a Euro-American worldview who’s going to sit me down for psychotherapy and tests, or do I do what my grandmother is suggesting and see a traditional healer?” A lot of times, folks don’t know which direction to turn, and that can create some confusion as well in terms of access.

What would you say to prospective psychologists, Native or not, about the mental health workforce needs of Native American communities?

They’re desperately needed. Not only in terms of American Indian psychologists to be working with American Indians, but we also need cross-culturally-competent non-Indian psychologists as well. We need to be able to respond administratively, to provide Indian and non-Indian psychologists that are cross-culturally competent who can serve as policymakers and hospital administrators, that can be employed within the IHS, as well as the tribes. We need to be able to respond in terms of policy for folks in those kinds of positions. The need is everywhere, it’s widespread. It isn’t that we just need more Indian therapists out there. We need everything: administrators, policymakers, researchers, academics, and more. We need representation of American Indian people.

Our non-native, majority culture psychology allies are invaluable as well. We may never have enough Indian psychologists to meet all those needs, but if we’re careful and thoughtful about recruiting and being open to improving our allies and the work that they do for us, then we stand a much better chance. The need is across the board.

Likewise, what would you say to working mental health care professionals?

I would say to not be afraid to educate themselves. If you’re a non-Indian health care provider, ask yourself “what do I know about the needs of Native populations that live around me, in my county or state? What do I know about their worldview?” Do some reflection.

Most people care. I truly believe that. We all get into these fields because we do want to help and we do want to be competent and do the best work that we can. I really believe—and I’ve found this over the course of traveling to different reservations, working as a consultant, through my private practice, and certainly being in this position since 1992—that there’s an army of folks out there that are concerned about what’s happening on our reservations, but sometimes they hesitate to get involved. They’d like to help, but they don’t know how and they’re not even sure how to get started.

I would encourage working professionals to first of all be thoughtful and be respectful that these tribes are sovereign nations, but by the same token contact the tribal health officers and tribal health directors or the service unit directors, the folks that know about the need. Ask questions: “I’m a lawmaker; what can I do to help?” “I’m a psychologist in Bismarck. What kinds of problems do you folks have out there? What can I do to help?”

If you don’t do that, then we don’t know you’re a potential ally until you step up. Don’t be afraid. If you care, then don’t be afraid to reach out and try and find a role for yourself to be able to help.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.