Historical Trauma: The Confluence of Mental Health and History in Native American Communities
"If we do not find a way to change this epidemic, we will have done what the bullets, the treaties, the boarding schools did not do. We will have succeeded in probably eliminating Indian culture in a meaningful way because there just won't be very many of us left who are healthy enough to pass it on."
Life expectancy: 74 years, 4 years below all races in the US. Alcohol dependency rates are three times higher than the national average, and almost twenty percent of deaths are related to alcohol. "Native Americans represent less than two percent of the US population but they make up eight percent of those who are homeless...It's estimated that up to 70 percent of Native Americans will suffer some sort of mental disorder during their lifetimes."
That's over' 45,000 homeless Native Americans and 4 million more suffering from mental illness; people experiencing their own individual realities day in and day out. Considering the demographics, those numbers are extraordinarily anomalous.
There is a public health crisis plaguing Native American communities in our country. And there's not enough visibility for this epidemic. And not enough is being done to address it.
Open up a new window, enter in a cursory Google search, and you'll find numerous hits on the tragic and truly disgraceful history of the "white man" and Native Americans: a history of cultural sublimation, identity suppression, deculturation, exploitation, and forced exodus. To go even further, tribal nations have had a long and protracted struggle for their sovereignty in the face of the US trustee relationship. "Chief Justice John Marshall set Native Americans on the path to poverty in 1831 when he characterized the relationship between Indians and the government as 'resembling that of a ward to his guardian.'" Nearly every decision directly impacting Native American lives is made by the federal government, which owns all of their land and governs their land.
With this comes a mandate to govern responsibly, with the best interests of the governed at heart. This "guardian" relationship, to use Marshall's characterization, has continued the gross inequality and inadequacy that has become the norm in Native American communities.
To put it more bluntly, the US government has failed its mandate to these communities, and there have been seismic negative repercussions.
"The removal of American Indians from their lands, as well as other [deculturation] policies has resulted in the high rates of poverty that characterize this ethnic minority group. One of the most robust scientific findings has been the association of lower socioeconomic status with poor general health and mental health." - National Institutes of Health
There is a term that is widely used to describe the legacy these policies have had from generation to generation: historical trauma. The pain and anguish over the forcible separation from their homeland, the determined wave of cruel cultural suppression and stigmatization from their government and through the popular media, the daily injustices of discrimination and inequality have all created (and continue to create for Native Americans of all ages across the United States) a reality of invisibility and darkness.
One Native American community leader interviewed for a UC Davis research project talked about the collision of history and community:
"I am dealing with people who have been disenfranchised and their mental illness originates in the system around them, the environment, the surrounding historical trauma. They are not crazy, they are people responding to trauma in their life."
Suicide has achieved a tragic and heartbreaking frequency in Native communities, as it is 9 to 19 times more frequent for them than for other ethnic groups. One child welfare official reports that, "it feels like wartime...I'll see one of our youngsters one day, then find out a couple of days later she's gone. Our children are self-destructing." But they're just responding to the intergenerational and persistent pressures that are in front of them day after day because of their ethnic background.
The loss of cultural richness and connection to previous generations and ancestors is not only a subliminal subtext in these communities; it is tangible, pervasive, and real. Listen to these young Native Americans talk about their relationship with their culture, the historical trauma they see all around them, and their community's fight to maintain and strengthen its connection to its ever-fading culture.
Hanging onto their culture is of the utmost importance in Native communities. However, in the face of the historical trauma that is plaguing them, these cultures are not aligned in a way that can effectivel y(at least through a Western medicine perspective) address the mental health crisis it faces. For many Native cultures, mental health was not historically compatible in the culture or language: there were no linguistic or cultural cognates to depression, suicide, or other manifestations of historical trauma.
"Among one AIAN (American Indian and Alaska Native) group, the North Plains people, the concept of mental illness was imposed in 1889 when the first federal mental hospital for an ethnic group, "The Hiawatha Asylum for Insane Indians,' was established. It was believed that a 'separate institution for Native Americans was needed because they had unique mental health afflictions.' The asylum was developed during a time when the US Congress had passed a federal law that prohibited AIAN people from practicing their own customs and the spiritual rituals indigenous to their culture and ways of life. Indeed, AIAN ceremonies and spiritual rituals were considered criminal activities and were punishable by federal law." - Donna Grandbois, North Dakota State University
Yet, those "unlawful" spiritual rituals and ceremonies are central to Native culture, which is, in turn, central to a Native American community. One Native American healthcare provider noted that, "belonging to a community is so important to native people, and so someone coming from an individual culture that is based on individualism might miss that whole thing." "Native culture is a system of care even though it is not classified as such," said another.
"AIAN groups stress the development of the inner life, which is reflected in the outer world through respect for all things. Likewise, the events of the outer world speak to inner processes for the person...that is to say, every event is in relation to all other events, regardless of time, space, or physical existence. Health exists only when there are balance and harmony in the inner and outer domains of life. In the relational worldview, helpers and healers are taught to understand problems through the balances and imbalances in the person's relational world. Furthermore, they are taught to see and accept complex interrelationships that can be influenced by entering the world of the client and manipulating the balance-imbalance phenomena." - Donna Grandbois, North Dakota State University
Hearing the personal anecdotes about historical trauma and looking over the table above, it's not hard to see the clear incongruity present between Native culture and the dominant culture of the "white man." It's not surprising, then, that there is a public mental health crisis among Native American communities, just due to the cultural and historical aspects.
But when you factor in the structural disparities that are either intentionally overlooked or intentionally kept in place (or maybe a little of both), the full picture comes into view.
"Growing up...I always just thought that white people were healthy and Indian people were drunk and violent."
"The real reason that there are no services is because of racism and discrimination. The State has money but it never has given any of that money to people that need services. There are no under-served or unserved populations here, [just] populations that are discriminated against." - Native American provider
The imperialistic relationship of domination by the federal government towards Native peoples in the United States has lived on far beyond the Trail of Tears and other forced removal policies. Since the relocation and consolidation of these populations to the reservations of Oklahoma, Texas, and other surrounding lands, their subjugation became less overt, guised under the veil of institutional respectability and authority.
Structural violence is defined as any systematic technique deployed to prevent or not fully fulfill the needs of a specific targeted group or population. "Structural violence is subtle, often invisible, and often has no one specific person who can (or will) be held responsible," which helps reinforce its invisibility to the greater, unaffected population to whom this is a foreign experience.
"One would think with the advancements we have made in education and research regarding our history, there would be more respect for the indigenous people who tended the lands and made enormous contributions to the history and building of this country and the Americas in general. But, once again, the Native American voice is symbolically being put back in reservations by those in office and the public." - Jamie Nicole Rocha
The Indian Health Service (IHS), a federal agency under the Department of Health and Human Services HHS), is the institution directly charged with providing accessible and culturally-competent health care to Native populations across the country. The IHS is the fulfillment of the federal government's "legal and moral obligation," through numerous signed treaties and Executive Orders, to take care of the health disparities present in Native communities.
However, it's not an exaggeration to say that the government doesn't take this mandate nearly as seriously as it should.
The best barometer of a government's priorities is where it puts its money: in the 2016 US federal budget, 26 percent ($994,650,662,844) of overall spending went to HHS, yet only $5.1 billion (0.5 percent) of that money went to the IHS. According to some estimates, "if health needs were the variable used to calculate the budget, the baseline funds necessary to address basic health care needs for AIAN people would be around $19.4 billion," almost four times greater than the budget allocation.
Specifically for mental health care, "it is clear that AIANs receive the least amount of federal assistance though their health burder is the most severe...while greater that one-third of the demands on health services in AIAN communities involve mental health- and social services-related concerns, the IHS line item mental health budget has hardly increased in the last 20 years."
Because of the trustee relationship between the federal government and the Native peoples, the IHS is the primary source of health care for those communities:
"Approximately 60% of Native Americans rely on the IHS to provide for their health care needs, yet funding for IHS has not kept pace with medication cost inflation and population growth. As a result, IHS services are under-funded, and patients are routinely denied care. The budget for clinical services is so inadequate that Indian patients are frequently subjected to a 'life or limb' test. That is to say, their care is denied unless their life is threatened or they risk immediate loss of a limb. Care is denied or delayed until their condition worsens and treatment is costlier or, all too often, comes too late to be effective."
This type of care is unthinkable in other communities; if a hospital in a predominately white neighborhood deployed a similar strategy as their care provision MO, the outrage would be deafening. Newspapers would dedicate invaluable column inches to an investigative report on the horrific medical malpractice, and cable news shows on CNN and Fox News would be saturated with interviews with enraged patients who were turned away from receiving care.
Yet, that's not the response when that hospital is on a reservation and when the patients are indigenous.
That's not the response to stories like that of Barbara Jean Franks of Juneau, Alaska:
"When my son died by suicide at age 23, I didn't even know how to think. I couldn't imagine that hope existed."
There are scores of other invisible tragedies like Barbara's happening every day in our country, many of which are preventable.
And yet, they continue to happen.
"Yet, still, we are waiting, and sometimes even fighting, just to be seen."
This post was originally published on Medium on July 6, 2016.