Stress & Trauma Toolkit
for Treating Indigenous People in a Changing Political and Social Environment
Clinical Vignette
Miles, 24 years old
Miles is a 24-year-old Mescalero Apache man with a history of depression and post-traumatic stress disorder (PTSD) who was referred for evaluation of suicidal ideation by the counselor at his college. He was assessed by the behavioral health counselor and referred to the psychiatrist in an Indian Health Service clinic in the large southwestern city where Miles is living. Miles described feeling very down, isolated, and is having trouble concentrating in his college art classes. He attends a college that specifically teaches Indigenous studies, and he has a good peer and family support system. With a history of feeling hopeless and worthless, Miles has contemplated recklessly running into traffic, because “no one would miss me.”
Miles grew up on his home Indigenous nation. He is very connected to living there. Miles participated in community cultural events and ceremonies and immersed himself in athletics in high school. He was a well-known cross-country runner. Miles was ambivalent about attending college off his Indigenous nation; he was not sure he would be able to leave the support of the rural reservation life. However, his parents strongly encouraged him to attend college in an urban setting because of its focus on Indigenous studies.
In a patient history interview with the psychiatrist, Miles explained that he spent three months at the Standing Rock encampment in 2016, where he assisted in maintaining the camp and helped produce articles and videos for social media. Miles felt very accepted and valued during his stay at the encampment. There were many Indigenous youth with similar backgrounds. However, police forcibly broke up the encampment and removed protestors—including Miles— spraying them with fire hoses and arresting them. Since returning from the encampment six months ago, Miles has been hyper-vigilant and irritable, with feelings of hopelessness and a lingering sense of not belonging.
Miles has attempted to engage with other college students who had been at the camp to increase his sense of belonging, which has helped. But he also has felt singled out by his white professors and suspects this is because of his activism. Miles feels his professors are unsure he is committed to his studies and are not sure how to engage him. While he is a bright student, he feels the teachers also feel threatened by him.
Miles is fearful of being arrested again; seeing law enforcement officers in the city where he attends college triggers these fears and hypervigilence. Miles is considering dropping out of college and returning to his home reservation because he feels overwhelmed by the pressures of living in the city and the triggers from law enforcement.
Back to Top
Factors that Put Indigenous Peoples at Risk for Mental Health Problems
Historical trauma: The psychological effects of forced relocation, assimilation, and other traumas inflicted on Indigenous peoples linger today. Indigenous peoples are confronting the trauma, learning the accurate history, and reconnecting with Indigenous spiritual practices and culture to assist the healing journey—but continuing discrimination and ongoing trauma hinder that progress.
Intergenerational Trauma: The intergenerational and unconscious grief from the historical trauma experienced by Indigenous peoples is passed from generation to generation due to forced relocation, land dispossession, and loss of spiritual practices, language and culture. If not addressed and identified accurately, depression, anxiety, PTSD, and substance use can be outward manifestations of the intergenerational trauma and unresolved historical grief.
Racism, racial bias, and discrimination: Racial and ethnic minority populations, including Indigenous peoples, often experience negative social factors such as bias and discrimination that contribute to poor physical and mental health.
- Institutional racism and social determinants of mental health: Institutional racism worsens social determinants of health and mental health, including access to quality education, safe housing, gainful employment, appropriate health care, and a clean environment.
- Low socioeconomic status (SES): Indigenous peoples tend to have disproportionately low socioeconomic status, as determined by education, income, and occupation. Low SES has been significantly associated with a higher risk for mental illness.
Geographic challenges: Many Indigenous people live in urban centers. They may have relocated to these areas for economic opportunities, but in the process may lose the cultural strength that comes from connection to the land. This may contribute to limited resources in terms of health care, mental health, education, and employment.
Difficulties integrating traditional and modern lifestyle: Indigenous persons may struggle to achieve a comfortable balance between tribal traditions and the demands of contemporary life.
Lack of culturally appropriate diagnoses and treatments: Diagnoses such as PTSD have been found to be relevant, but inadequate for capturing the scope of responses to historical trauma experienced by Indigenous peoples. The literature has identified a need to develop appropriate culturally based trauma theory and interventions for Indigenous peoples.
Back to Top
Suggested Assessment and Treatment Recommendations
- Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
- Avoid stereotypes and create a welcoming environment that acknowledges and respects the impact of complex histories and traumas of Indigenous peoples. Providers should recognize their own biases towards Indigenous peoples and acknowledge where they are in their own learning and awareness of Indigenous culture and experience. Providers who maintain openness and curiosity about patients with whom they work can achieve cultural agility and sensitivity.
- Encourage patients to reconnect with their culture and community to reinforce identity, resilience, and self-esteem. This can prevent and protect against symptoms of mental illness, especially substance use issues, depression, and PTSD.
- Use cultural practices as primary and adjunctive treatment modalities. Talking circles and drumming circles may be useful as primary treatment modalities or secondary to other treatments. Indigenous peoples have strong connections to this way of healing and connecting to their culture and transmitting Indigenous knowledge. Providers may employ culturally appropriate activities like these with guidance from Indigenous providers. Other ideas to consider are to integrate Indigenous art and aesthetics that are part of the local Indigenous nations in office settings. Providers who regularly treat Indigenous people should consider becoming familiar with local customs and acknowledge traditional territory to show cultural humility and sensitivity.
Back to Top
References
- Brave Heart, M.Y.H., Elkins, J., Tafoya, G., Bird, D., & Salvador (2012). Wicasa Was'aka: Restoring the traditional strength of American Indian males. American Journal of Public Health 102(S2), 177-183.
- Brave Heart, Maria Yellow Horse. The historical trauma response among Natives and its relationship with substance abuse: A Lakota illustration. Journal of Psychoactive Drugs 35.1 (2003): 7-13.
- Coyhis, Don, and Richard Simonelli. "The Native American healing experience." Substance use & misuse 43.12-13 (2008): 1927-1949.
- Dickerson DL, Venner KL, Duran B, Annon JJ, Hale B, & Funmaker G. (2014). Drum-Assisted Recovery Therapy for Native Americans (DARTNA): Results from a Pretest and Focus Groups. American Indian and Alaska Native Mental Health Research, 21(1), 35-58. Doi:10.5820/aian.2101.2014.35
- Dickerson, DL. “Utilizing Drumming in American Indians/Alaska Natives in Substance Use Disorders: A Focus Group Study. Am Journal Drug Alcohol abuse, 2012 Sep:38:(5):505-510. Else IR, Andrade NN, Nahulu Linda B. Death Stud. 2007 May-Jun;31(5):479-501.
- Goldberg, David. "Lessons from Standing Rock-Of Water, Racism, and Solidarity." The New England Journal of Medicine 376.15 (2017): 1403-1405.
- Kauanui, J. Kehaulani editor, Speaking of Indigenous Politics: Conversations with Activists, Scholars, and Tribal Leaders. University of Minnesota Press, 2018.
- Kauanui, J. Kehaulani. Speaking of Indigenous Politics: Conversations with Activists, Scholars, and Tribal Leaders. University of Minnesota Press. 2018.
- Substance Abuse and Mental Health Services Administration (SAMHSA), Tribal Technical Advisory Committee, Indian Health Services, National Indian Health Board (2016): National Tribal Health Agenda. Rockville, MD: SAMHSA http://store.samhsa.gov/shin/content//PEP16-NTBH-AGENDA/PEP16-NTBH-AGENDA.pdf Suicide and suicidal-related behaviors among indigenous Pacific Islanders in the United States.
Back to Top