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CHAPTER 13 Theory of Self-Reliance
John Lowe
Growing up Cherokee has everything to do with my understanding of self-reli- ance. Being one of 22 doctoral prepared Native American nurses in the United States provides another perspective of who I am. The historical context of my people has shaped me and my scholarly work.
Cherokee historians, scholars, and tribal leaders have noted that the histori- cal background and distinct culture of the Cherokee should be known in order to understand and respect the Cherokee today (Henson, 2001; Mooney, 1975; Perdue, 1989). Historically, the Cherokee were the mountaineers of the South. They considered themselves inheritors of a dignity beyond their simple means and referred to themselves as the “principle people” (Ehle, 1988). The way of life and roles for them began to change under the new federal government of George Washington. Most of the land owned by the Cherokee was taken away through government treaties and force of arms. The federal government also established the Indian Boarding Schools where the language and practice of traditions were prohibited. This restriction was done in an attempt to strip the Native American of his or her identity.
It is important to me that Cherokee identity shines through in this chapter on the middle range theory of Self-Reliance. The theory arose from Cherokee values and the work is being shared because I think these core values have meaning for the broader population of Native American people as well as indigenous people throughout the world. In fact, the values that I learned as a Cherokee have the potential to affect health for populations beyond Native American and indigenous people.
■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED
Self-reliance has been noted by Native American leaders to be the mainstay and way of life that infl uence the health among Native American people (Tyler, 1973). Additionally, self-reliance has been recognized as a key variable for keeping Cherokees in balance (Stuart, 1993). The history of the Cherokee has continued to affect the physical, emotional, psychosocial, economic, and spiri- tual well-being of the people. Formal and informal leaders and tribal members
Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0013
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of Cherokee communities have expressed concern about the lack of self-reli- ance among their members. Historical events are viewed as undermining self- reliance, which in turn decreases well-being. The purpose of the middle range theory of Self-Reliance is to articulate a process for promoting well-being with attention to appreciation for one’s culture.
Growing up Cherokee, I observed that Native American people who became disconnected from the culture were plagued with health problems. These observations were the foundation of my commitment to make a difference for my people. My father, who stayed connected and grounded in Cherokee values, often said: “The Cherokee way is best.” I later came to understand that self-reliance characterized the Cherokee way. Then, in my PhD program, I conducted an ethnographic study to understand the meaning of self-reliance for Cherokee people and how it was exhibited in daily life (Lowe, 2002b). A follow-up ethnographic study was conducted to explore how self-reliance was characterized and achieved during adolescence particularly among Cherokee males (Lowe, 2003). The three concepts of the Self-Reliance Theory, being responsible, disciplined, and confi dent, were the themes that emerged from these studies. The self-reliance instrument was developed based on these con- cepts (Lowe, 2006).
Foundational Literature
The knowledge of the historical background and distinct culture of Native Americans has been noted as important to increase the understanding of this group today (Henson, 2001). Historically, the Cherokee inhabited the south- east region of the United States that now includes the states of Virginia, West Virginia, Tennessee, Kentucky, North Carolina, South Carolina, Georgia, and Alabama (Mooney, 1982). The way of life and roles of the Cherokee and most Native Americans changed dramatically as a result of the dispossession of land and culture through government treaties and force of arms. The establishment of the Indian Boarding Schools was among the events that undermined self- reliance of Native Americans. The traditional dress and speaking the tribal language were prohibited in an attempt to strip Native Americans of their identity. The physical, emotional, psychosocial, economic, and spiritual well- being of the Cherokee continues to be impacted today by prohibitions enforced decades ago.
Self-reliance is a concept within the Cherokee holistic worldview where all things are believed to come together to form a whole (Altman & Belt, 2008). Cherokee tribal leaders have noted self-reliance to be the mainstay and way of life that infl uences the health of the Cherokee people, helping them to fi nd and keep balance (Henson, 2001; Stuart, 1993).
Social change has been widespread in Native American populations, chal- lenging the traditional way of life, values, and relational systems. The Native American family is changing rapidly as family members must now work
13 . THEORY OF SELF -REL IANCE 291
outside the home, threatening the closeness of the family, in contrast to earlier years when families worked closely together to survive in a hostile environ- ment (Frank, Moore, & Ames, 2000). Many Cherokee elders and tribal lead- ers report that the interdependence (Cherokee self-reliance) of the family, clan, and the tribe of earlier years has eroded (Lowe, 2002a), leading to stress- related health outcomes. Stress and coping processes have been reported to play an important role in physical and mental health outcomes among Native Americans (Walters & Simoni, 2002). For instance, Native American youth have signifi cantly greater emotional distress than their White peers, and much of their distress is related to social and cultural factors (Bergstrom, Miller, & Peacock, 2003).
Assumptions
The cultural themes that constitute the assumptions of the theory are “being true to oneself” and “being connected.” These assumptions cut across all the three concepts of self-reliance. The fi rst assumption, “being true to one- self,” refers to acknowledging one’s heritage and living in keeping with the worldview of one’s culture. The worldview of the Cherokee that provides the roots for this theory is considered to be circular and holistic where all things are believed to come together to form a whole (Altman & Belt, 2008). The second assumption, “being connected,” refers to identifying and utiliz- ing resources within creation. According to this dimension of the worldview, each person is a resource within the creation. The gifts and talents of each person will benefi t not only the person but also the family, community, and cultural group. One identifi es and utilizes his or her own gifts and talents and those of others.
■ CONCEPTS OF THE THEORY
Self-reliance is being true to self and is lived by being responsible, disciplined, and confi dent while staying connected to one’s cultural roots. The three con- cepts of self-reliance are (a) being responsible, (b) being disciplined, and (c) being confi dent.
Being responsible is being accountable to care for self and to care for oth- ers by getting assistance, respecting self, respecting others, and respecting the Creator. Respecting others occurs by being dependable and accountable. Honoring traditions, values, and language is a way to respect the Creator. The Creator in this context is the life force that grounds a sense of self.
Being disciplined is setting goals and pursuing goals by taking the initiative to make decisions and taking risks necessary to achieve goals. After decisions are made and goals are set, the pursuit of goals occurs by creating a plan, get- ting assistance, and redirecting one’s effort.
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Being confi dent refers to having a sense of identity and self-worth. Self- worth refers to knowing self within one’s cultural heritage, being proud of one’s heritage, and accepting cultural values and beliefs.
■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL
The Model of Self-Reliance (Figure 13.1) depicts a pattern of interrelating cir- cles in keeping with a holistic world view. The three interlocking circles in the center of the model describe the interrelatedness through intertwining and interlacing of the concepts.
■ USE OF THE THEORY IN NURSING RESEARCH
Lowe began a program of research focused on substance abuse in Native American communities while in graduate school at the master’s level. His thesis research explored the social support that contributes to abstinence after substance-use treatment in the Native American young adult. The research identifi ed the overall concept of self-reliance as the mainstay and way of life that infl uences the health and well-being of Native Americans. During his PhD
Self-reliance
Being true to oneself
Being responsible
Being confident
Being connected
Caring for self Caring for others
Setting goals Pursuing goals
Having a sense of identity Having a sense of
self-worth
Being disciplined
FIGURE 13.1 Self-Reliance. Source: Reprinted with permission from Lowe, J. (2003). The self-reliance of the Cherokee male adolescent. Journal of Addictions Nursing, 14, 209–214.
13 . THEORY OF SELF -REL IANCE 293
studies, he continued to explore how the concept of self-reliance is defi ned by the Cherokee since self-reliance for the Cherokee had not been defi ned or researched previously. His PhD dissertation utilized the ethnographic method to identify how (a) self-reliance is conceptualized by the Cherokee; (b) the adult Cherokee perceives, achieves, and demonstrates self-reliance; and (c) nurses and healthcare professionals can incorporate the Cherokee concept of self-reliance in healthcare (Lowe, 2002b).
Lowe investigated the Cherokee adolescent’s perception of self-reliance and its relationship to health (Lowe, 2003), fi nding that self-reliance was a way to keep the Cherokee from abusing drugs or alcohol. Participants in his stud- ies reported a mentoring relationship, described as “being infl uenced,” that is essential to enhance self-reliance (Lowe, 2005). The Cherokee Self-Reliance Model that emerged from the fi ndings of these studies was used to guide the development of a series of intervention studies. A Cherokee self-reliance instru- ment was developed and tested in the intervention studies. The instrument is a 24-item questionnaire with a 5-point Likert scale. A reliability coeffi cient alpha of 0.84 was documented for the instrument when it was used with Cherokee adolescents (Lowe, 2006).
Lowe fi rst conducted a pilot study funded by the Association of Nurses in AIDS Care/Biotech. The “Cherokee Teen Talking Circle” was evaluated for its effect on HIV/AIDS knowledge and attitudes as well as protective behaviors. Cherokee self-reliance was also measured as a variable in this pilot study. The participants included 41 high school students who completed a 2-hour Talking Circle intervention. Pretest to posttest scores on HIV/AIDS knowledge and attitudes and protective behaviors were studied with paired t tests. There were signifi cant differences in knowledge (pretest mean: 4.44 + 0.92; posttest mean: 4.83 + 0.38) and attitudes (pretest mean: 9.88 + 0.38; posttest mean: 10.68 + 1.31). Cherokee self-reliance and HIV/AIDS knowledge, attitude, and pro- tective behavior at posttest was signifi cantly (p < .01) correlated (knowledge [0.499]; attitude [0.421]; behavior [0.254]; Lowe, 2008). In addition, the Talking Circle was demonstrated to be a feasible cultural approach, resulting in mean- ingful participation with study participants.
In a postdoctoral study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Minority Supplement to R01 AA 10246-05 S1 Teen Intervention Project (TIP), Lowe conducted a Talking Circle intervention to help adolescents address alcohol and substance abuse problems. The par- ent TIP research was built on the standardized Student Assistance Program (SAP). The SAP involved a 10-session motivational, skills-building group intervention, developed for use with eighth through 12th graders (Wagner & Waldron, 2001; Wagner, Drinklage, Cudworth, & Vyse, 1999). This group intervention utilized a traditional group setting, approach, and process. The core ideas of the SAP were merged with Cherokee values through the Talking Circle intervention to create the Teen Intervention Project—Cherokee (TIP-C; Lowe, 2006).
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Findings of the pilot TIP-C research revealed that the average Drug Use Screening Inventory—Revised (DUSI-R) score of the TIP-C participants (N = 108) reduced from 24.74 to 20.94 (t = −13.82, p < .001). The participants’ average stress score also decreased from 43.60 at the baseline to 41.44 postintervention (t = −6.41, p < .001). By contrast, the participants’ average Cherokee self-reli- ance score increased from 90.51 at baseline to 110.92 postintervention (t = 26.97, p < .001; Lowe, 2006). During each follow-up assessment, TIP-C participants were encouraged to write about the impact of the intervention. One partici- pant, who completed his 1-year follow-up assessment, had been diagnosed and was receiving treatment for cancer at the time of his written feedback. He said: “I am so thankful that I went through the TIP-C groups . . . even though I have been very sick, this has been one of the best years of my life . . . I have been clean and sober and I now know what it means to live the Cherokee way.”
Lowe conducted another 3-year study “Community Partnership to Affect Keetoowah–Cherokee Adolescent Substance Abuse” funded by the National Institute on Drug Abuse (NIDA; 1 R01 DA021714). A community-based par- ticipatory research (CBPR) approach was used to develop and test the cultur- ally competent school-based intervention—Cherokee Talking Circle (CTC)—a revision of the TIP-C intervention. The difference in substance abuse, Cherokee self-reliance, and stress between Keetoowah–Cherokee adolescents who received the CTC prevention and those who received standard substance abuse education (SE) was evaluated. Findings revealed that higher self-reliance and less focus on self were related with the ability to express feelings, which was higher for those who scored higher on self-reliance. Substance abuse scores between the CTC and SE groups were signifi cantly different (F = 13.14.10, p < .001) with the CTC group having lower substance abuse scores. There was also a signifi cant interaction effect between time and group (F = 27.95, p < .001) with the greatest differences between the groups noted immediately after the intervention (t = −3.89, p < .001) and at the 3-month follow-up (t = −4.69, p = .001). At each time point, self-reliance was higher for the CTC group than the SE group and the difference between the groups increased over time (Lowe, Liang, Riggs, & Henson, 2012).
Lowe conducted a 2-year NIDA (R34DA029724) funded study to examine the feasibility of using the CTC for Native American sixth graders as they tran- sition to middle school. In this study, results revealed a trend toward statistical signifi cance. At 6 months postintervention, the CTC group had signifi cantly lower substance involvement/interest scores than the SE control group. CTC substance abuse/use scores decreased from 2.3 to 1.3 (t (33) = 1.8, p = .007). Cherokee self-reliance scores increased from 90.5 at baseline to 110.9 postinter- vention (t = 26.97, p < .001; Lowe, Liang, & Henson, 2016).
A 5-year NIDA (R01DA029779) funded study was recently conducted by Lowe and colleagues that was guided by the Self-Reliance Theory. This study tested a school-based, brief motivational intervention for substance abuse among Native American high school students. At the time when this study
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was conducted, there was no evidence from research concerning the use and effect of motivational interviewing among Native American youth guided by a cultural-specifi c theory such as the Self-Reliance Theory.
Lowe is currently conducting a NIDA/NIAAA funded (R01DA035143) project that proposes to evaluate an after-school substance abuse prevention intervention; the Intertribal Talking Circle (ITC), targeting sixth grade Native American youth in three tribal communities: Ojibwe/Chippewa in Minnesota, Choctaw in Oklahoma, and Lumbee in North Carolina. A CBPR approach is being used to culturally and technologically adapt the ITC as an innovative virtual Talking Circle intervention. A two-condition controlled study is being used to evaluate the effi cacy of the ITC to increase Native American youth self-reliance while decreasing Native American youth substance-use involve- ment. An adult training program second-level intervention study is also being conducted to train tribal personnel from the three regional tribes on how to implement the ITC intervention as a tribal program beyond the study period. Effectiveness is being determined by a small partial crossover randomized trial comparing ITC intervention to a Wait-List Control (WLC) condition. Process evaluations are focusing on the future adoption and implementation of the ITC, and recommendations for sustainable adaptations. The project is also building Native American capacity to address health disparities, as experienced native investigators are mentoring three junior native investigators.
Lowe has collaborated with researchers nationally and internationally, shar- ing the self-reliance work and the community-based participatory approach that he uses for his research. For instance, he collaborated with Native American colleagues to expand the Cherokee Self-Reliance Model so that it is appropriate for other tribes, renaming the model “Native Self-Reliance.” The Native Self- Reliance Model has been used to guide a study where the Talking Circle inter- vention was implemented with Plains tribal youth (Patchell, Lowe, Robbins, & Hoke, 2015). From an international perspective, Lowe has begun work with indigenous people in Australia (Aboriginal and Torres Straight Islanders), Canada (First Nation), New Zealand (Maori), and Panama (Kuna) who are interested in a community-based approach to research, the Self-Reliance Theory, and the process of using the Talking Circle. Australian, Canadian, New Zealand, and Panamanian colleagues recognize Lowe as a scholar who advo- cates for culturally competent healthcare of Native Americans and indigenous people globally. When in international settings, Lowe meets with indigenous nurses as well as community elders who seek his counsel.
■ USE OF THE THEORY IN NURSING PRACTICE
The Talking Circle is a meaningful approach to nursing practice. It is described here as it is lived in the Native American tradition. Nurses in practice are invited to consider how the Talking Circle may be used in other cultural traditions.
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In the Native American tradition, a Talking Circle is a coming together and a place where stories are shared in a respectful manner and in a context of com- plete acceptance by participants. Native Americans have long used the circle to celebrate the sacred interrelationship that is shared with one another and with their world (Simpson, 2000). The idea of the Talking Circle permeates the traditions of Native Americans to this day. It symbolizes an entire approach to life and to the universe in which each being participates in the circle and each one serves an important and necessary function that is valued no more or no less than that of any other being.
By honoring the circle, human beings honor the process of life and the pro- cess of growth that is an ever-fl owing stream in the movement of life energy (Garrett & Carroll, 2000). Cherokees consider the whole greater than the sum of its parts and have always believed that healing and transformation should take place in the presence of the group since they are all related to one another in very basic ways (Reed, 1993). Through use of the Talking Circle, Native Americans can use the support and insight of their brothers and sisters to move away from something, such as substance abuse, and toward something else. In this way, the Talking Circle has served a very sacred function of healing or cleansing, while also serving as a way of bringing people together.
The traditional sense of belonging and comfort provides healing for all and the circle reminds the Cherokee of life and their place in it (Ywahoo, 1987). Each person comes to the circle as a human being with his or her own concerns, and together participants seek harmony and balance by sharing stories, pray- ing, singing, talking, and sometimes even just sitting together in silence.
■ USE OF THE THEORY IN NURSING EDUCATION
Lowe has long used the Talking Circle approach in his work with nursing stu- dents. Every semester he takes a group of students to tribal communities in Oklahoma to participate in a service learning cultural immersion experience where the Native American culture and community become the classroom. Self-reliance is threaded throughout this learning experience. The Talking Circle became a powerful teaching approach that emerged from the Self-Reliance Theory, offering opportunities for personal growth that extend beyond the community nursing content that is the focus for the course. Lowe and a former doctoral student conducted a study using the Talking Circle approach to gain a deeper understanding of what was learned and meaningful about the cultural immersion experience (Lowe & Cirilo, 2016). A Native American elder, leader, and cultural expert facilitated the Talking Circle sessions. The students who participated in the Native American cultural immersion experience and study were from various cultural backgrounds such as Caucasian, African American, Haitian, Hispanic/Latino, Middle Eastern, Asian, Caribbean, Russian, Irish,
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and South African. The Talking Circle approach for the study provided a set- ting that facilitated the nursing students to share openly and with ease con- cerning the cultural immersion experience. The nursing students shared how they were required to leave their work/job situations, school duties, families, and children behind during the cultural immersion experience in Oklahoma. This encouraged and allowed them to let go of their usual responsibilities and make themselves completely available for the experience. As a result, the nurs- ing students described the experience as an opportunity to learn about others, teach them, grow with them, be with them, and to learn about themselves in a self-reliant way they have never experienced.
■ CONCLUSION
The Theory of Self-Reliance has roots in Native American culture and values. It has grown over time as a foundation guiding the Talking Circle intervention used in nursing research, practice, and education. The theory is strengthened by the existence of a psychometrically sound instrument that enables evaluation of self-reliance through self-report. The middle range theory of Self-Reliance in this chapter is an expression of invitation to nurses who may choose to use the theory for practice, research, and education. Use of the theory will honor the Native American people who cultivated self-reliance in the midst of unimagi- nable historical trauma. The theory is shared in a spirit of gratitude for the wis- dom of ancestors and in a spirit of generosity, wishing to extend their wisdom to others who may benefi t from the middle range theory of Self-Reliance.
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