Stress & Trauma Toolkit

for Treating Indigenous People in a Changing Political and Social Environment

Indigenous populations in the United States are diverse in languages, cultures, and histories. As a result, varying experiences and responses to historical traumas have emerged in the present in these populations. Historical trauma has been defined as “cumulative emotional and psychological wounding, over the lifespan and across generations, emanating from massive group trauma experiences.”

Witnessing or being directly involved in violent struggles carries risks, both physical and psychological, which can be passed on to the next generation. For Indigenous peoples, land dispossession, forced relocation, epidemics, and forced assimilation and sterilization are just some examples of the collective losses they have experienced over time.

Unfortunately, these losses continue even today in disputes such as those at Standing Rock that perpetuate stressors on Indigenous people. Indigenous populations have demonstrated strengths of resiliency by continuing their cultures, language, subsistence lifestyles, spirituality, and ceremonies. Indigenous peoples have also used activism as a way of life to collectively come together and resist oppression and land and water dispossession. The Standing Rock Dakota Access Pipeline protests in 2016, has raised awareness in mainstream America of the historical oppression, forced relocation, and land dispossession experienced by Indigenous people for centuries.

However, other responses to intergenerational traumas in Indigenous populations may include substance abuse, depression, anxiety, low self-esteem, anger, and suicidal thinking.

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.

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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.

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Suggested Assessment and Treatment Recommendations

  1. Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  2. 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.
  3. 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.
  4. 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.

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Resources

APA Mental Health Facts for American Indian/Alaska Natives. 2017 https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-American-Indian-Alaska-Natives.pdf

APA CME Module: Cultural Competence Curriculum, “Providing Culturally Competent Care to Indigenous Peoples: American Indian/Alaska Native/Native Hawaiian.” 2016.

APA Best Practice Highlights: “Native American Patients” 2016. Indigenous cultural competency self-assessment checklist. Indigenous Corporate Training, Inc, 2016. http://www.ictinc.ca/blog/indigenous-cultural-competency-self-assessment-checklist

Umbreit M. Talking Circles. Center for Restorative Justice & Peacemaking, August 2003. https://www.nacc.org/docs/conference/2014/M4%20-%20Talking%20Circles.pdf

References

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Authors

  • Linda Nahulu, M.D
  • Mary Hasbah Roessel, M.D.
  • Samra Sahlu, M.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.