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Trauma in American Indian Communities
by Aaron Morsette SAMHSA Trauma Intervention Specialist
What is Posttraumatic Stress Disorder?PTSD affects individuals' of all races, ages and religious affiliations (APA, 2000). The conceptualization of PTSD stems largely from a Western mental health perspective. It suggests that PTSD is caused by witnessing or directly experiencing an event in which a person felt that they were at risk of losing their life. As a result of this experience an individual develops a set of symptoms or responses that include persistent thoughts pertaining to the event, avoiding thinking about the event, and an increased sense of arousal, or being on guard. These physical and mental responses create a decrease in functioning.
What types of events are considered traumatic?There are many incidents that may cause an individual to develop PTSD. Initially, PTSD was largely looked at in veterans who were returning from war. As time has passed it has become more and more evident that PTSD affects a large number of people from all different populations. Events such as natural disasters or acts of terror can lead people to develop PTSD. Individuals who have suffered from domestic violence and children who have witnessed domestic violence can develop PTSD symptoms. Children and adults who have been in car accident or who have witnessed community violence are at risk of experiencing PTSD symptoms.
How many American Indians suffer from PTSD?Through out the US it has been reported that 8% of the population experiences PTSD (APA, 2000). At this point in time there has not been a lot of research that assesses the rates of PTSD in American Indian populations. The research that has been conducted suggests that American Indians suffer from PTSD at a greater rate in comparison to the general population (Yellow Horse Brave Heart, 2003). In fact, data indicates that 22% of American Indians have PTSD (Yellow Horse Brave Heart). In American Indian adolescent populations the rates may be higher. In one population of American Indian adolescents it was found that 96% of children had witnessed at least one traumatic event and 75% had some symptoms of PTSD (Morsette et al., 2006).
Are there differences in PTSD symptoms in American Indian populations?There are so many American Indian tribes in the US and nearly every tribe has different creation stories, dances, language, and customs. On top of these vast differences among tribes there are also individual differences among American Indian people. Some American Indians have lived in reservation communities for their entire life, while others were raised in more urban areas. Additionally, some American Indians follow their traditional customs more closely than others. Given all of these differences it is impossible to lump all American Indians into one category and say that what holds true for one tribe also holds true for another tribe. Nevertheless, across multiple tribes there are some factors that should be considered in the cause of PTSD symptoms.
Historical TraumaIt has been suggested that American Indians, as a result of the loss of life, land, and destructive government policies, suffer from a legacy of historical unresolved grief, which shares PTSD symptomatology and since the losses of American Indians have never been openly acknowledged; many have not undergone the grieving process that facilitates healing (Brown & Goodman, 2005; Morissette, 1994; Yellow Horse Brave Heart & DeBruyn, 1998). In recent years historical trauma has gained increased attention in American Indian populations (Whitbeck, Adams, Hoyt & Chen, 2004). Many older and middle-aged American Indians have responded to this idea and have developed traditional ceremonies to treat individuals suffering from possible historical trauma (Morrissette, 1994; Whitbeck et al., 2004; Yellow Horse Brave Heart & DeBruyn, 1998; Yellow Horse Brave Heart, 2003). Although some American Indians may experience historical trauma it is also possible that others may experience PTSD symptoms stemming from on-going losses and/or traumatic experiences.
Loss and violence exposure among American IndiansMany American Indians experience significant losses every year (Stahl & Chong, 2002). According to Indian Health Services (IHS, 1999) Native Americans and Alaskan Natives suffer from and subsequently die from diabetes at a greater rate than all other races and ethnicities combined in the United States. The leading causes of death among Native Americans and Alaskan Natives ages 1-14 are accidents, and homicides. The leading causes of death among this same population ages 15-24 are accidents, suicide and death. For those aged 25-44 the leading causes of death are accidents followed by chronic liver disease and cirrhosis, which are usually attributable to excessive alcohol use. Again, these rates of death are higher among Native Americans and Alaskan Americans, compared to all other races in the U.S (IHS, 1999). Given these high rates of death and dying it is likely that many Native Americans begin experiencing losses, and thus may also be more likely to be exposed to violence at a young age. What are the consequences of experiencing such losses, particularly losses due to sudden and traumatic circumstances? As noted, psychological literature suggests that one must witness or directly experience the loss in order to develop PTSD. Yet, recent studies suggest that children may develop PTSD symptoms from experiencing losses, this has also been shown in American Indian adolescent populations (Cohen, Mannarino & Knudsen, 2004; Cohen Mannarino, Deblinger, 2006, Morsette et al., 2006). This evolving idea is known as Childhood Traumatic Grief (CTG).
Childhood Traumatic GriefChildhood Traumatic Grief (CTG) results from the loss or death of a loved one through traumatic circumstances, which also includes unexpected deaths such as a heart attack (Cohen, Mannarino & Knudsen, 2004; Cohen, Mannarino, Deblinger, 2006). CTG shares PTSD symptoms but does not require that the child is present at the time of the loss. (Cohen et al., 2004). CTG results when children because of the development of PTSD symptoms that result from the loss, are unable to process the loss and proceed through the normal grieving process. In American Indian adolescent populations children frequently report that although they have witnessed violence, and have PTSD symptoms it is the loss of friends and relatives that is causing those PTSD symptoms (Morsette et al., 2006). CTG has not yet been looked at in adults.
Are there negative impacts of PTSD?It seems that there are many negative impacts related to PTSD. In children it is often difficult for them to concentrate in school because they are constantly thinking about the traumatic event. They may fall behind their peers and may exhibit behavioral problems that lead to trips to the principal's office (Vanderbleek, 2004). Children and adults may have difficulty sleeping at night and may feel disconnected from other people (APA, 2000). Adults may also find it hard to focus at work and even care for their children. PTSD is also usually associated with depression (Davis & Siegel, 2000). PTSD has been connected with criminal behavior and alcohol abuse (Koss et al. 2003; Wood, Foa, Layne, Pynoos & James, 2002).
Is there help for PTSD?As we have already seen, PTSD is relatively common in Caucasian populations, as well as American Indian populations. As a result there are many different treatments available. The primary treatment used to treat PTSD is known as Cognitive Behavioral Therapy (CBT; Harvey, Bryant & Tarrier, 2003; Hembree, Foa, Dorfan, Street & Tu, 2003). CBT usually teaches a person about their symptoms. In other words, it help increase a person's understanding of their thoughts, feelings and behaviors relationship to the traumatic event. Individuals are also asked to recall the traumatic event in detail, which helps decrease anxiety related to the event. Finally, people are taught anxiety management skills.
Have treatments for PTSD been used with American Indians?Many of the treatments that are available have not included American Indians in their development. Nevertheless, there are forms of CBT that have been used in an array of American Indian populations such as Trauma Focused CBT, Eye Movement Desensitization and Reprocessing (EMDR; Cohen, Mannarino & Knudsen, 2004). However, the use of these treatments has been on an individual basis and research has not examined how effective they are in American Indian populations. One program, referred to as Cognitive Behavioral Intervention for Trauma in Schools (CBITS) has been used with American Indian adolescents in multiple reservation communities. The results from this project suggest that it is an effective program in American Indian adolescent populations. In fact, 75% of children who participated in CBITS demonstrated a decrease in PTSD and depressive symptoms (Morsette et al., 2006).
Are there cultural factors that should be considered?Tribal leaders frequently state that in order to heal one must address the "physical, spiritual, emotional and mental" domains of the self. Treatment programs often address only the emotional and mental components of mental health. Depending on a person's belief system they may need to seek care from tribal healer, or in some cases receive additional services from these individuals. Living a balanced life has always been an integral aspect of healthy American Indian living. The people are dependent on the family and the tribe and the family and tribe are dependent on the people. Addressing individual mental health helps ensure continuity in the revolving circle of American Indian life for "our children and our children's children."
Aaron Morsette is a member of the Chippewa Cree Tribe of the Rocky Boy Reservation in Montana. He attends the University of Montana and is pursuing a PhD in clinical psychology. He serves as a Trauma Intervention Specialist for the Montana Center for the Investigation and Treatment of Childhood Trauma at the Division of Education and Research Services on the campus of UM, conducting trauma research on the Rocky Boy Indian Reservation in Montana.
Brown, E., & Goodman, R. (2005). Childhood traumatic grief: An exploration of the construct in children bereaved on September 11. Journal of Clinical & Adolescent Psychology, 34 (2), 248-259.
Cohen, J., Mannarino, A., Knudsen. (2004). Treating childhood traumatic grief: A pilot study. Child & Adolescent Psychiatry, 43 (10), 1225-1233.
Cohen, J., Mannarino, A., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. Guilford Press, New York, NY.
Davis, L., & Siegel, L. (2000). Posttraumatic stress disorder in children and adolescents: A review and analysis. Clinical Child and Family Psychology Review, 3, 135-154.
Harvey, A., Bryant, & Tarrier, N. (2003) Cognitive behavior therapy for posttraumatic stress disorder. Clinical Psychology Review, 23, 501-522.
Hembree, E., Foa, E., Dorfan, N., Street, G., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from therapy for PTSD? Journal of Traumatic Stress, 16, 555-562.
Indian Health Services. (1999). Trends in Indian Health. U.S. Department of Helath & Human Services, Indian Health Services, Office of Planning, Evaluation & Legislation, Division of Program Statistics, Author.
Morrissette, P. (1994). The Holocaust of First Nation people: residual effects of parenting and treatment implications. Contemporary Family Therapy, 16 (5), 381-392.
Morsette, A., Swaney, G., Schuldberg, D., Stolle, D., & van den Pol, R., Neff, M. (2006). Cognitive Behavioral Intervention for Trauma in Schools (CBITS): A culturally responsive method of treatment on rural American Indian reservation. IN-Progress.
Stahl, M, & Chong, J. (2002). Substance abuse prevalence and treatment utilization among American Indians residing on-reservation. American Indian and Alaska mental health research,10, 1-23.
Whitbeck, L., Hoyt, D., Johnson, K., & Chen, X. (2006). Mental disorders among parent/caretakers of American Indian early adolescents in the North Midwest. Social Psychiatry and Psychiatric Epidemiology. 41(8), 632-640.
Wood, J., Foy, D., Layne, C., Pynoos, R., & James, B. (2002). An examination of the relationships between violence exposure, posttraumatic symptomatology and delinquent activity: An "ecopathological" model of delinquent behavior among incarcerated adolescents. Journal of Aggression, Maltreatment, & Trauma, 6, 127-147.
Yellow Horse Brave Heart, M. (2003). Historical trauma response among Natives and its relationship with substance abuse: A Lakota illustration. Journal of Psychoactive Drug, 35, 7-13.
Yellow Horse Brave Heart, M., & DeBruyn, L. (1998). The American Indian holocaust: Healing historical unresolved grief. The Journal of the National Center, 8, 60-79.
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