Pioneer woman

Like many of her American Indian peers in graduate school, Tami Jo De Coteau, a Turtle Mountain Chippewa, dreamed of using her clinical psychology doctorate to serve her people. She was motivated by the high rates of suicide and domestic violence, as well as the lack of health and mental health services, on reservations.

Yet by the time they graduated, many of her peers had lost their enthusiasm for working with American Indians, she says, often because they simply didn’t get much experience working with the population in school. They felt their clinical skills were no match for the complex mental health problems, severe poverty, high rates of alcoholism and generational trauma that loomed over reservations.

“My friends were going to the reservation and then leaving, or not going at all, because they felt so underprepared to do the work that needs to be done in Indian country,” says De Coteau.

That’s now changing, thanks to De Coteau’s efforts to generate more psychology training slots on reservations. After earning her PhD at the University of Nebraska, Lincoln, De Coteau built from scratch a psychology internship program at the Standing Rock Reservation, an hour outside of Bismarck, N.D. Now in its third year, the program is the only psychology internship program primarily located on a reservation and administered by an American Indian tribe in the United States. It is APPIC-accredited and in APA’s accreditation pipeline.

De Coteau, who won the 2010 American Psychological Foundation/Div. 29 (Psychotherapy) Early Career Award for creating the program, says not only is it thriving, it’s also attracting attention as a model for other reservations.

“Indian people are experts at discerning a person’s level of genuineness,” says De Coteau. “If they don’t see you as invested in the work you’re doing, they won’t come back and see you for counseling. We know we’re doing a good job because people are coming back. They are coming back and even asking for specific interns again.”

Life on the ‘rez’

De Coteau didn’t grow up on a reservation, but her father did, on the Turtle Mountain and Fort Berthold reservations in North Dakota. He chose to raise his family in Bismarck and neighboring cities in central North Dakota so his children would have access to a better education.

To prepare herself for unfamiliar territory, De Coteau gained experience working on reservations, first through a self-designed practicum at the Omaha reservation in Nebraska during graduate school, then during her internship at the Department of Veterans Affairs Black Hills Health Care System, where she worked at a clinic for Indians in the nearby reservation town of Ashland, Mont. That’s where De Coteau met Art McDonald, PhD, the first enrolled Indian to earn a PhD in psychology and a longtime advocate for training Indians in psychology.

“We talked about how we could use interns in these very remote areas of Indian country to provide services,” she says. As they saw it, bringing in the interns would serve two purposes: providing much needed mental health care and training them to be qualified professionals who could work on other reservations.

With McDonald’s help, De Coteau applied for and won a Graduate Psychology Education grant under the VA Black Hills Foundation to expand the psychology internship she had attended at the VA. The funds allowed the VA to hire De Coteau, add interns and expand its services through two satellite clinics, one on the Cheyenne River Reservation, serving veterans and nonveterans, and another at a community mental health center in Ashland. At the Ashland clinic, interns counseled reservation and nonreservation Indians, local ranchers and Amish people — a total “multicultural immersion,” says De Coteau. “We also learned a lot about what it took to provide good service in those communities,” she says, such as the importance of working with interns on how to build trust with clients, respect Indian culture and project sincerity.

In 2007, she used that experience to pitch the idea of an internship program to the Standing Rock Sioux tribe back in her home state of North Dakota. The tribal leaders of the Standing Rock reservation, which has one of the highest suicide rates in the United States, liked the idea so much they allocated a portion of their tribal health money to fund her program.

As she structured the internship, De Coteau also counseled clients as an independent consultant for the tribe. She discovered quickly that the people in Standing Rock believe that mental health providers don’t stick around long. Providers, such as those from the U.S. Public Health Service, tended to come in droves after a suicide, then leave. To offset those feelings of abandonment and mistrust, De Coteau devoted much of her time that first year to attending tribal events, building relationships and convincing people she aimed to stay.

“Out here, people don’t trust you until you demonstrate that you are trustworthy,” says McDonald. “You have to establish credibility or you won’t have clients.”

McDonald is now co-writing a grant application with De Coteau to replicate her internship program on the Northern Cheyenne Reservation in Montana.

A model of self-care

In addition to running the internship program, De Coteau also sees clients, each day driving an hour from her home in Mandan, N.D., outside of Bismarck to reach the Indian Health Service clinic at Fort Yates. Every week, her interns spend one day either providing individual and group therapy at Chambers and Blohm Psychological Services, a rural group practice in Bismarck, or working at West Central Human Service Center, a community mental health center. For the rest of the week, they join De Coteau on the reservation, seeing patients at the outreach or IHS headquarters clinics or making home visits, often driving long distances across the 2.3-million-acre reservation to see clients.

“These students go above and beyond because we don’t have additional funding for mileage,” says De Coteau. “We pick students who are committed to this kind of work.”

De Coteau pairs each intern with a “care coordinator,” who is a member of the Sioux tribe, for home visits. Care coordinators help the interns navigate cultural differences and make introductions to families. While much of their work is crisis-oriented, such as counseling people affected by a suicide, some of their work is preventive, says De Coteau. One example is their foray into equine-assisted psychotherapy, in which they use horses to help people open up about their problems.

“Equine-assisted psychotherapy is very culturally appropriate for Indian people,” particularly children and teenagers, says De Coteau. “Horses have very good instincts and are very responsive to their environment, and so are Indians.”

With McDonald, De Coteau and her interns have hosted two equine-assisted psychotherapy camps for children whom they’ve identified as being at a high risk for suicide. Each child is paired with a horse and told to guide it through an obstacle course without touching or speaking to the horse. The children have access to props, such as a rope they can loop around the horses’ necks.

“Once the children get the idea they can think outside the box, their confidence level spikes and they get very creative about getting their horse through these obstacles,” she says.

The exercise often helps these children and teenagers talk about their problems and feel less despondent about their lives, says De Coteau. One teen she worked with had conduct disorders and substance abuse problems. Shortly after the training, he had an explosive argument with his father. Such fights were common in his household and typically ended with the boy being arrested for vandalism or something similar, says De Coteau. But after having worked with De Coteau, the boy went directly to the police station, told police he had fought with his father and asked for help.

“When kids complete [the] therapy, we see them making better choices and being more effective in their problem-solving,” says De Coteau. “They will ask for help and keep asking, rather than giving up.”

She and her staff have since worked with the boy and his extended family to find a temporary placement for him to keep him out of the foster care system.

Successes like that one don’t come every day, admits De Coteau. The work can be disheartening for interns, which is why De Coteau stresses self-care with them.

“I always give interns a little speech about how we are the Marine Corps of psychology internships, except that we have moccasins on the floor instead of boots,” says De Coteau. “Military combat units survive off their morale and, similarly, our team morale is important to our longevity.”

She has her interns do team-building exercises, such as writing a mission statement that helps them stay focused, and she encourages them to exercise, cook, do yoga or seek therapy on their own. She models self-care as well, says Bismarck practitioner Terri Hanson, PhD, who is an internship training supervisor. A mother of three children under age 5, De Coteau is “special and exceptional” in the way she handles the stress of her job, Hanson says.

“At times when another person might throw up her hands or let frustration out when it wouldn’t be helpful, she never does that,” says Hanson. “She has good balance and good boundaries in her life.”

One of De Coteau’s strategies is to “shut off” during her hourlong drive home from the reservation each night. Once she’s home, she makes the effort to always be in the moment with her children. “My kids are what help me balance my work,” says De Coteau.

Working on the reservation is particularly challenging at times, but it’s very meaningful to her. “When I drive into the reservation, I do see the problems, but I also see the possibilities and solutions,” says De Coteau. “The Native American culture is beautiful, and the people are strong, and I learn so much from working here.”