Denise Middlebrook, PhDCommunity Intervention Director
Kauffman & Associates, Inc.
Trauma in AI/AN CommunitiesTrauma in AI/AN Communities
C lt lCultural•“What broke our world apart”
(Gathering of Native Americans)
Historical• long‐term and cumulative exposure to traumatic events
(Yellow Horse Brave Heart & DeBruyn,1998; Yellow Horse Brave Heart, 2003; Beals et al., 2002; Morsette, 1994; Morsette et al., 2006)
Trauma in AI/AN CommunitiesTrauma in AI/AN CommunitiesTrauma in AI/AN CommunitiesTrauma in AI/AN CommunitiesIntergenerational
•Unresolved trauma that is internalized and passed on from generation to generation
•Trauma is normalized. “It’s just the way things are here on the rez.” (Elder from Northern Plains Tribal Community)
PresentPresent•Trauma experienced today
•Higher rates of death due to disease•Aggravated assault twice that of the country as a wholegg y•Violent death accounts for 75% of AI/AN youth in late adolescence and early adulthood•Highest rates of meth use•PTSD•PTSD
(IHS,1999; D.S. Bigfoot, 2007;Stahl & Chong, 2002; Cohen et al., 2004; Cohen et al., 2006; Morsette et al., 2006; NCAI, March 2009)9)
Consequences of Trauma :Consequences of Trauma :AI/AN Community Risk FactorsAI/AN Community Risk Factors
Loss of lands, culture, language, subsistence or traditional way of lifelife
Continued pressure to assimilate
Feelings of being torn between two different worlds
Intergenerational post‐traumatic stress disorder g p
Consequences of Trauma :Consequences of Trauma :q fq fAI/AN Community Risk FactorsAI/AN Community Risk Factors
SES levels: Ongoing and pervasive poverty, high unemployment, lack of academic achievement, and economic opportunity
L k f th “ t it t b i d t i ”Lack of the “opportunity to be industrious”(Northern Plains Tribal Leader)
Dependence on TANF and other subsidies
Low community self‐esteem(Chandler & Lalonde, 2003)
Low community expectations for success
Consequences of Trauma :Consequences of Trauma :q fq fAI/AN Community Risk FactorsAI/AN Community Risk Factors
Community‐level hopelessness, learned helplessness
Alcoholism/drug use
Community violence
Community shameCommunity shame
Highest rates of youth suicide in the country
Family disruptionHigh rates of unemploymentLow academic achievementPovertyPovertyLack of economic opportunityFamily stressful life events and trauma
b bSubstance AbuseSpousal and Child AbuseStigma around seeking mental health treatmentg gLack of information about youth violence, bullying, and warning
signs for suicide
Gender
Age
History of mental health problemsd i h l i killdepression, hopelessness, poor coping skills
Friends or family members who have attempted or completed suicide
Alcohol use/abuse
No father at home
(IHS 1998‐99;CDCWISQARS; Mason et al 1989; Grossman et al 1991); Howard‐Pitney et al (IHS, 1998 99;CDCWISQARS; Mason et al., 1989; Grossman et al., 1991); Howard Pitney et al., 1992; Gartrell, et al., 1993)
Suicide rates by ethnicity and age group Suicide rates by ethnicity and age group United United Suicide rates by ethnicity and age group Suicide rates by ethnicity and age group ‐‐‐‐ United United States, 2000States, 2000‐‐20052005
30
35
on
20
25
0,00
0 po
pula
tio
Eur-Amer NonLatino
Afr-Amer NonLatino
Native American
Asian-PI
10
15
Rat
e pe
r 100 Latino
0
5
00-04
05-09
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64 65
+
0 0 1 1 2 2 3 3 4 4 5 5 6
Age Group in years
Source: CDC vital statistics
Suicide rates by region for persons aged 0Suicide rates by region for persons aged 0‐‐19 years 19 years –– U.S., 1989U.S., 1989‐‐1998 1998 , 9 9, 9 9 9999
(U.S. average rate 3.03)(U.S. average rate 3.03)Portland 7.70 Billings 8.08 Aberdeen 19.07
WA
ORID
MT
WY
ND
SD
MN
WI
MIME
Bemidji 8.94
Phoenix 7.71
NE IA
IN PA
NY
CA
California 3.48
KS
TN NC
NVUT
AZ
CO
Percentile
3 4
Tucson 18.25 TX
OK
LA
MS AL
95‐10075 ‐9450 ‐ 740 ‐ 49
FL
SCAZ NM
Navajo 7.31
Albuquerque 7.25 Nashville 2.54
49
AK
Alaska 23.77Oklahoma City 3.11
Stressful Life events:• Acute personal trauma• Acute personal trauma• Chronic personal trauma• Community Trauma• Bullying and other forms of violence• Physical illnessy• Multiple home placements
PTSD
Unresolved Grief
Frequent contact with criminal justice system
Family and community instability
Parental unemployment
(Bigfoot, 1988; Manson et al.,1989 Howard‐Pitney et al.,1992; Middlebrook, et al., 2001)
Boarding Schools
Cultural conflict and pressure to acculturate
Disruption of cultural values
Identity conflict
Lack of recreational opportunity
Lack of educational opportunity
Poverty
(Berlin, 1985; Hochkirchen & Jilek, 1985; Lipschitz, 1995)( , 9 5; J , 9 5; p , 995)
Factors associated with resiliency:Higher levels of self‐esteemHigher levels of self‐esteemSense of Self EfficacyCultural valuesCommunity supporty ppFamily Support
Strong maternal figures
Spirituality
Strong sense of identityStrong sense of identity
(Goodluck, 2002; Tester and McNicoli, 2003; Goodluck & Willeto, 2004; LaFromboise et al, 2006)
Family SES levelyAlcohol and drug free familiesHealthy familiesIntact communitiesIntact communitiesPositive Attitude toward schoolSchool Athletics and other recreational activitiesA d i hi t/Academic achievement/successGood communications skillsRecognition for achievementEnculturation
(Howard‐Pitney et al., 1992; Zimmerman et al.,1998; Goodluck, 2002; Chandler and Lalonde, 2003; Goodluck & Willeto, 2004; LaFromboise et al, 2006)a d a o de, 003; Good uc & eto, 004; a o bo se et a , 006)
A i I di d Al k N i A i I di d Al k N i American Indian and Alaska Native American Indian and Alaska Native Prevention ProgramsPrevention Programs
Middlebrook, D., LeMaster, P., Beals, J., Novins, D., & Manson, S. 2001. Suicide Prevention in American Indian and Alaska Native Communities: A Critical Review of Programs. Suicide and Life‐Threatening Behavior, 31,
132‐149.
Institute of Medicine Guidelines
1) Well‐defined risk and protective factors
2) Targeted population group
3) The intervention itself
4) The research design used to test the program4) The research design used to test the program
5) Evidence concerning the implementation
6) And evidence concerning the outcomes
School‐based School based Risk Factors
Suicide potentialPsychological distressPsychological distressStressful life eventsAlcohol and drug use
Protective FactorsProtective FactorsCoping, self‐efficacy, problem solvingCommunication skillsInformation on suicideInformation on suicideGoal settingCultural & Spiritual development
(LaFromboise & Howard‐Pitney, 1994, 1995)
School & Community‐basedSchool & Community basedUse of “Natural Helpers” Risk Factors
Alcohol and drug abuseAlcohol and drug abuseChild abuse ,violence between intimate partnersTraumatic death or injurySuicide Suicide
Protective FactorsSelf‐esteemTeam buildingTeam‐buildingCommunity EducationScreening
(Serna May Sitaker 1998)(Serna, May, Sitaker 1998)
School & Community‐basedRi k F tRisk Factors
DepressionSuicide of friends & family membersAlcohol and drug abuseAlcohol and drug abuseCommunity violenceChild abuse & neglectCrimeCrimeHigh unemployment, lack of job skills
Protective FactorsC lt l & S i it l tiCultural & Spiritual practicesImproving community relations
( )(Tower, 1989)
Community‐based, Residential Treatment Facility, Out‐Patient trainingtraining
Risk FactorsDepressionAlcohol and drug abuseAlcohol and drug abuseUnresolved griefFamily history of suicidePhysical health problemsy p
Protective FactorsSpiritual and Cultural ConnectionsMoral developmentMoral development
(Fleming, 1994 )(Fleming, 1994 )
School & Community‐BasedRisk Factors
SuicideDepression, despairl k f i l & i t iti i t t tlack of social & economic opportunities, persistent povertySome tribal normsPressure to acculturate
Protective FactorsProtective FactorsSelf‐esteemPhysical HealthCultural Connectedness
(Davis, Hunt, & Kitzes, 1989)
Traveling clinic Risk Factors
DepressionAlcoholismSuicideEconomic privationBroken homesEmotional problems
Protective FactorsNone Reported
(K h & D lk 88)(Kahn & Delk, 1973, 1975, 1988)
At‐Risk Incarcerated Youth, Community‐basedRisk Factors
socioeconomic and interpersonal factorsself‐destructive behaviorsalcohol & inhalant use,cultural identity confusionchild‐rearing practicesgender
Protective FactorsNone Reported
(Di l Sh l L & Sh (Dizmang, et al., 1974; Shore et al., 1972; Levy & Shore, 1977
School & Community‐basedRisk Factors
Alcohol abuseLoss of historyyLoss of ethnic identityFamily breakdown
Protective FactorsNone Reported
(Fox et al.,1984)
Urban School & Community‐basedRisk Factors
Alcohol and drug abuseLack of community identificationyCoping skillsPoor nutrition & health
Protective FactorsDecision‐makingSelf‐esteemPersonal identity
(Dorpat, 1994)
Summary and Recommendations for Prevention Program DevelopmentPrevention Program Development
Data Development
Risk Factors for Youth SuicideRisk Factors for Youth Suicide
Evaluation of Interventions to Prevent Youth S i idSuicide
Suicide Prevention Services
Public Information & Education
B d A h Broader Approaches
Encourage research focused on AI/AN youth Encourage research focused on AI/AN youth resilience
Fund community participatory researchFund community participatory research“nothing about us without us”
Bring tribes to the table from the beginningBring tribes to the table from the beginning
Bring tribal youth to the table
Improve & fund suicide prevention initiativesImprove & fund suicide prevention initiativesFund school‐based prevention
Community‐based preventiony p
Involve youth in program development
Create partnership with tribes for improving their p p p gown culturally‐based interventions
Improve collaboration between county and state mental health systems
Public/Private Partnerships
I di H lth S iIndian Health Servicesmental and physical health services in every communitycommunity
Increase the number of qualified native mental health professionals
DHHSAI/AN youth mental health initiatives
Capacity development initiatives
Reservation Infrastructure Development InitiativesInitiatives
recreation
economiceconomic
education
roadsroads
transportation
housingg