Violence and Residual Associations Among Native Americans Living on Tribal Lands

Adam Hardy, Kathleen Brown-Rice

The article reviews the empirical literature regarding exposure to violence among Native Americans living on tribal lands. The prevalence of various types of violence experienced by this population is identified. Predictive characteristics correlated with higher rates of violence among Native Americans living in tribal communities have been reported by researchers to include socioeconomic status, unemployment, gender, cultural affiliation, substance abuse, relationship status, history of violence exposure, and adverse childhood experiences. Residual associations include PTSD, anxiety, depression, chronic pain, substance abuse, promiscuity, suicidal ideation, communal deterioration, and cardiovascular disease. Barriers for addressing mental health needs in this population, implications for mental health counselors and directions for research are provided.


Keywords: Native Americans, tribal lands, violence, predictive characteristics, residual associations


The treatment of Native American populations has not been a traditional area of focus among mental health researchers (Matamonasa-Bennett, 2013). However, a push for increased knowledge in the effective treatment of this population has led to an influx of empirical attention in the past few decades. The National Congress of American Indians declared violence against Native Americans, particularly those living on tribal lands, as the most critical issue faced by Native Americans (Matamonasa-Bennett, 2013). Complicating the interpretations of the subsequent studies, Evans-Campbell (2008) concluded significant differences between Native Americans living on tribal lands and Native Americans living in urban areas. It is critical that counselors be cognizant of such within- group differences (Brown-Rice, 2013). Research efforts related to Native American populations living in tribal communities have predominately focused on exposure to violence. In order to bridge the gap in understanding how violence impacts Native Americans, the current review addresses the prevalence, predictive characteristics and residual associations related to violence among Native American men and women living on tribal lands. Moreover, the barriers to addressing mental health treatment among this population are discussed. Implications for counselors and directions for research are provided.


Violence and Mental Health Issues for Native Americans


Violence can consist of physical, sexual and emotional assault (Watts & Zimmerman 2002). Many acts of violence can be characterized as a combination of these categories, such as a sexual assault that also produces physical harm to the survivor. Physical violence can include assault, neglect of basic needs (which is most common among children), exploitation of labor and false imprisonment. Sexual violence includes rape, fondling, genital mutilation and sex trafficking (Watts & Zimmerman, 2002). Emotional violence includes isolation, verbal abuse, economic abuse, coercion, threats and intimidation (Pence & Paymar, 1993). Because violence is often conceptualized as a means to gaining or maintaining power and control over others, a survivor of violence is often victimized by those closest to him or her, such as a family member or friend (Watts & Zimmerman, 2002).


     Post-traumatic stress disorder (PTSD) has been associated with exposure to physically, sexually and emotionally violent experiences (Ford, Grasso, Elhai, & Courtois, 2015). Traumatic stress symptoms are often more complicated to treat in circumstances when an individual has been exposed to prolonged or repeated violence. Furthermore, these symptoms are more likely to develop when survivors of violence feel a sense of betrayal from the perpetrator, which is often reported by those who experience sexual assault and domestic abuse (Ford et al., 2015). Researchers have concluded that these issues are more prevalent among Native Americans living on tribal lands (Malcoe, Duran, & Montgomery, 2004; Yuan, Koss, Polacca, & Goldman, 2006), which may suggest a higher likelihood for the development of PTSD when compared to other populations.


Although PTSD is the mental health disorder most often associated with individuals who experience violence, depression (Cascardi, O’Leary, & Schlee, 1999) and anxiety (Pico-Alfonso et al., 2006) symptoms have been highly correlated to violence exposure. Clearly, those who survive violence are at high risk of developing mental health symptoms and can benefit from professional intervention. However, the experiences of Native Americans related to violence are not likely to be completely congruent to other populations (Sue & Sue, 2012). For this reason, it is crucial for counselors to gain increased competency in the unique factors impacting the Native American community in order to provide effective care.


Violence Against Native American Women


United States legislators acknowledged in the 2005 Violence Against Women Act (VAWA) that Native American women living on tribal lands were a particularly marginalized population (Crossland, Palmer, & Brooks, 2013). VAWA mandated that several governmental organizations begin a series of research efforts in order to better understand the prevalence and residual consequences experienced by this population when violence was present (Crossland et al., 2013). Bryant-Davis, Heewoon, and Tillman (2009) concluded that the studies succeeding VAWA indicated that violence against women had significantly decreased in the 10 years preceding the studies for every population except Native American women. These researchers also concluded that Native American women living on tribal lands account for the highest rates of exposure to violence compared to any other population. Despite these conclusions, Matamonasa-Bennett (2013) reported that Native American women continue to be underrepresented in research regarding violence against women.


Prevalence of Violence Against Native American Women

Determining the precise prevalence of violence among Native American women living on tribal lands is a complicated endeavor. There can be substantial differences between communities, leading to frequent misinterpretation in the results of research (Yuan et al., 2006). It is common that researchers report the prevalence of violence among Native Americans, even though the results of their studies accounted for the prevalence among a specific tribe. For this reason, it is important not to make generalizations regarding reports that do not expand to various regions by examining the methodological decisions of the researchers in order to better interpret the results (Gone, 2010). In response to the need for clarity on the prevalence of violence in tribal communities, Oetzel and Duran (2004) concluded that many researchers asked vague questions and excluded common types of physical violence, prompting them to investigate exposure to violence among Native American women by asking a wider range of specified questions. They determined that women in tribal communities reported the prevalence of violence exposure at rates ranging from 46–91%. They compared these results to non-Native populations, which had previously reported prevalence rates ranging from 7–51%. Similarly, Wahab and Olson (2004) examined the prevalence of physical violence among Native American women living on tribal lands while accounting for vast differences between tribes. These researchers concluded that this population experienced higher rates of physical violence than women of any other ethnicity.


While researching violence among Native American women, many researchers have focused on domestic violence. In a study spanning 12 distinct tribal communities, researchers reported that 58.7% of Native American women had been victims of domestic violence, resulting in severe physical trauma in 39.1% of these women (Malcoe et al., 2004). Hart and Lowther (2008) reported domestic violence incidents had increased each of the past 10 years prior to their study, indicating that this issue is escalating in tribal communities. Moreover, Native American women have reported higher levels of re-victimization than other female populations (Urquiza & Goodlin-Jones, 1994). L. Jones (2008) concluded that Native American women living on tribal lands found it difficult to leave violent relationships due to communal feedback which encourages victims to protect their abusers. Because Native American women are more likely than other women to be recurrently assaulted, there may be implications for the development of complex traumatic stress symptoms (Ford et al., 2015).


Sexual assault also appears to be a common form of violence experienced by Native American women. Prevalence rates of rape among this population have been reported as high as 34.1%, which is nearly twice the rates among other women in the United States (Tjaden & Thoennes, 2000). Behaviors of perpetrators of sexual assault on tribal lands also have been studied among researchers. When surveyed about sexual assault history, Native American women living in tribal communities have reported male relatives as the most often cited perpetrator of sexual assault, accounting for 55% of the incidents (Yuan et al., 2006). Significant percentages of perpetration of sexual assault also have been attributed to romantic partners (46%), acquaintances (29%) and strangers (28%). The likelihood of developing complicated traumatic stress symptoms may be increased due to the high frequency of sexual assault of Native American women by individuals who are familiar to them (Ford et al., 2015). Moreover, it appears that once a Native American woman living on tribal land is exposed to sexual violence, the likelihood of subsequent exposure is high. The recurrence of sexual assault among this population has been reported to be as high as 79% (Roodman & Clum, 2001).


Predictive Associations of Violence Against Native American Women

Malcoe, Duran, and Ficek (2002) concluded that socioeconomic status is a significant predictor of exposure to violence among Native American women living on tribal land. Specifically, women who have reported low socioeconomic characteristics are two and half times more likely to be exposed to physical violence (Malcoe et al., 2002; Oetzel & Duran, 2004). Specifically, it was reported that Native American women living on tribal lands who were receiving governmental financial assistance were nearly two and a half times more likely to report exposure to physical violence. According to the United States Census Bureau (2014), less than half of the residents of the Pine Ridge reservation in South Dakota were employed between 2010 and 2014. As a result, 52.2% of those living in this area were below poverty standards, which is well above the national average of 14.8%.


     Native American women living on tribal lands with substance abuse issues are at a higher risk for exposure to both physical and sexual violence (Yuan et al., 2006). Substance abuse issues among individuals close to Native American women have been reported to predict exposure to violence. Native American women with alcohol abuse issues, for example, reported significant levels of exposure to domestic violence (Yuan et al., 2006). Furthermore, Native American women have reported heavy alcohol use by 62% of their perpetrators, compared to 42% from women of other ethnic backgrounds (Ferraro, 2008). There is evidence to suggest that Native American women living on tribal land who identify with traditional Native American culture are less likely to be associated with substance abuse and related physical violence (Whitbeck, Adams, Hoyt, & Chen, 2004). Conversely, Native American women living on tribal land who report higher associations with traditional Native American culture have reported increased frequency of exposure to sexual violence (Yuan et al., 2006). However, increased focus on traditional Native American culture could be a coping mechanism used by women following victimization, potentially making cultural affiliation a residual effect of violence.


When considering sexual violence, the factor most predictive of exposure in Native American populations has been concluded to be gender (Yuan et al., 2006). Both Native American men and women are sexually assaulted, but Native American women report sexual assault at rates 14 times higher than males (Yuan et al., 2006). The relationship status of women living on tribal lands also has been correlated to exposure to sexual violence. Women engaged in cohabitating relationships and women separated and divorced were concluded by researchers to be at a higher risk for sexual violence (Bryant-Davis et al., 2009). Moreover, Bryant-Davis and Ocampo (2006) postulated that Native American women are sexually assaulted at higher rates than women of other ethnicities due to systematic eroticization, devaluation and objectification by American culture.


     Yuan et al. (2006) reported that Native American women living on or near tribal lands who experience emotional abuse as children report significantly higher rates of sexual violence exposure as adults. Similarly, women in this population who have survived sexual and physical abuse before the age of 18 are more likely to be raped in adulthood. Because a history of emotional, sexual or physical abuse appears to significantly contribute to the predictability of future exposure to violent traumatic stressors, increased attention on providing interventions to young Native American populations may prove beneficial for prevention efforts (Yuan et al., 2006).


Residual Associations of Violence Against Native American Women

Arbuckle et al. (1996) concluded that Native American women are three times more likely to be murdered than Latino and White women. Hence, death is a relatively common residual association to violence among this population. Witnessing homicide also can be a form of exposure to violence. When homicide occurs, there are often secondary victims seeking mental health services. Family and friends of a victim of homicide within the Native American population often report cognitive patterns of self-blame, which exacerbates mental health symptoms (Weinberg, 1994).


Native American women exposed to physical violence have reported high levels of traumatic stress symptoms (B. Duran et al., 2009). In a study that surveyed 3,084 Native Americans living on tribal lands across the United States, women reported PTSD symptoms with a frequency twice the rate of men (Buchwald, Goldberg, Noonan, Beals, & Manson, 2005). It was concluded that 16% of women living on tribal lands met the criteria for PTSD, which is 6% higher than the national average for women (Ford et al., 2015). Exposure to violence on tribal lands also has been associated with increased likelihood to develop mood disorders, anxiety disorders (B. Duran et al., 2009) and chronic pain (Buchwald et al., 2005).


The relationship between exposure to violence in tribal communities by Native American women and mental health disorders was examined by Oetzel and Duran (2004). These researchers concluded that physical injuries and medical assistance on tribal lands were highly correlated with symptoms of depression and that increased exposure to violence appeared to lead to negative sociological effects such as unemployment. Oetzel and Duran theorized that exposure to physical violence on tribal lands could be directly linked to chronic pain and psychological symptoms which limit the capacity for Native American women to change their environment when desired.


It is common that persons exposed to violence display high-risk behaviors, including substance abuse and sexual promiscuity (Hobfoll et al., 2002). It is believed that these behaviors can be conceptualized as a means of coping with traumatic stressors (Ford et al., 2015). Substance abuse, which has been identified as a predictive factor to physical violence exposure, also appears to be a residual association. Saylors and Daliparthy (2005) concluded that Native American women often use alcohol and illicit drugs in order to numb cognitive and emotional reactions to physical and sexual violence. Furthermore, among Native American women living in tribal communities, those with a history of exposure to violence are five times more likely to contract sexually transmitted infections when compared to women with no history of exposure to violence (Hobfoll et al., 2002). As a result, this population is more likely to contract HIV than women in other communities. When the spread of sexually transmitted infections is intentional or the risks are disregarded by carriers, it can be conceptualized as sexual abuse, even when sex is consensual. When considering the spread of HIV, this act can be criminal (Hobfoll et al., 2002).


Despite the high rates of sexual assault victimization that have been reported by Native American women living on tribal lands, residual effects of exposure to sexual violence have not been a major focus by researchers (Bryant-Davis et al., 2009). However, there have been several associations that have been linked to rape. Similar to what researchers have concluded from studying the effects of exposure to physical violence, researchers have concluded that Native American women living on tribal lands who reported a history of sexual violence victimization display high frequencies of symptoms that meet the criteria for PTSD and other anxiety disorders (Bryant-Davis et al., 2009). Perhaps related to this phenomenon is the research indicating that this population has reported high levels of suicidal ideation and more frequent suicidal attempts than women in other communities following sexual violence exposure (Bohn, 2003). Among Native American women who attempted suicide in one tribal community, 87% reported exposure to some level of sexual violence and 59% reported exposure to rape (Bohn, 2003).



Violence Against Native American Men


     A review of the literature on violence experienced on tribal lands reveals that the majority of the focus has been on the prevalence, predictive factors and residual associations of exposure to violence among Native American women. Although men living in these areas have received less attention, it is important to be familiar with the available research related to the victimization of men. Gaining a broader understanding of how all individuals living on tribal lands experience violence will assist in the ability to be sensitive to issues faced by both men and women and aid counselors to choose culturally competent interventions.


Prevalence of Violence Against Native American Men

Robin, Chester, Rasmussen, Jaranson, and Goldman (1997) reported that among Native American men residing in Southwest tribal communities, 81% reported exposure to a violent act at some point in their lives. Among Native American men living on seven tribal communities in Montana, nearly one in ten reported exposure to physical violence in the year preceding the survey (Harwell, Moore, & Spence, 2003). This figure was nearly double the prevalence reported by women living in the same communities, although women reported higher frequencies of sexual violence and emotional abuse (Harwell et al., 2003). A study on the prevalence of aggravated assault among Native Americans living on tribal lands found that men were victims of severe physical violence at a rate of 36% since turning 18 years of age (Yuan et al., 2006). These reports suggested that although women may be exposed to various types of violence at higher rates in tribal communities, men may be subject to a higher likelihood of physical injury due to exposure to higher rates of physical violence.


Native American men are more likely than men of any other ethnicity to experience traumatic brain injury (TBI) as a result of violence (Nelson, Rhoades, Noonan, & Manson, 2007). Moreover, Native American men living in rural tribal communities are more likely to seek medical attention for a TBI than those living in urban areas (Nelson et al., 2007). Hence, a Native American man living on tribal lands appears to have a higher risk than any other population in the United States to experience severe enough violence to sustain an injury to the brain. The only comparable population was concluded to be African-American men living in urban inner-city communities (Nelson et al., 2007).


Although domestic violence is typically considered by many to be a women’s issue, Robin, Chester, and Rasmussen (1998) surveyed both men and women living on tribal lands about their lifetime and recent prevalence of intimate partner violence experiences. These researchers concluded that men reported rates of lifetime prevalence of domestic violence at 91%, with 31% reporting recent exposure to violence perpetrated by intimate partners. However, despite these high rates, men were concluded to be less likely to need medical assistance as a result of domestic violence when compared to the women in their tribal communities.


Predictive Associations of Violence Against Native American Men

     Homicide occurrence among Native American men living on tribal lands has been reported to be highly correlated to unemployment and impoverished standards of living (Lester, 1995). Criminal mentalities that often accompany a lack of occupational routine and structure may contribute to increases in the capacity to commit homicide (Lester, 1995). It is possible that factors that lead to unemployment, such as substance use, play a role in the propensity to experience or commit homicide in tribal communities (Koss et al., 2003).


Yuan et al. (2006) investigated the predictive characteristics of physical violence exposure among Native American men living in six distinct tribal communities, studying the effects of variations in demographics, alcohol dependence in adulthood, cultural variables, regional variables, and adverse childhood experiences on the prevalence for physical violence victimization. The researchers concluded that only adverse childhood experiences and alcohol dependence in adulthood mediated the likelihood of exposure to violence across similar communities.


Native American men under the age of 18 have been studied by researchers to determine predictive characteristics and protective factors related to the perpetration and exposure to physical violence. Pu et al. (2013) concluded that men under the age of 18 living on tribal lands have more desire to learn and practice traditional Native American culture than the women in their similar age ranges. The men who reported high levels of desire to practice their traditional culture also displayed higher levels of self-efficacy to avoid perpetration and victimization of physical violence. High levels of parental involvement were associated with lower levels of exposure to violence among this population.


Residual Associations for Violence Against Native American Men

     While the prevalence and predictive characteristics of exposure to violence among Native American men living on tribal lands have been understudied, there have been higher rates of contributions from empirical literature regarding the residual associations related to victimization. When surveyed using qualitative methods, Native American men reported that one substantial observed consequence of violence on tribal lands is the expanding discrepancies between traditional Native American values and behaviors witnessed in tribal communities (Matamonasa-Bennett, 2013). These men reported beliefs that Native American men did not frequently commit violence against Native American men or women until the introduction of colonization and alcohol. These men feared that continued trends in violence would serve to further the gap between the values held by traditional Native American culture and the values of those living on tribal lands.


Beals et al. (2013) studied PTSD among 1,446 Native Americans living in southwest tribal communities and 1,638 Native Americans living in Northern Plains tribal communities. Rates of traumatic stress symptomology that suggested PTSD were reported to vary between 5.9% and 28.3% for Native American men. On average, men reported rates of PTSD at 14.8%, which is approximately triple the national average for men (Ford et al., 2015). Therefore, although Native American women living on tribal lands have reported higher rates of PTSD than men, the discrepancy between the rates on tribal lands and the national average is far more pronounced for Native American men than it is for women. Beals et al. also concluded that Native American men were just as likely to develop traumatic stress symptoms (15.9%) as men in other populations following exposure to traumatic stressors. This indicates that the increased frequency of PTSD among Native American men living on tribal lands is a function of increased exposure to traumatic experiences. There also may be certain types of violence that lead to increased likelihood for the development of PTSD. Researchers have reported that sexual violence exposure has been associated with increased anxiety symptoms among Native American men (Gnanadesikan, Novins, & Beals, 2005). Furthermore, Native American men who have experienced six or more incidents of violence are significantly more likely to develop traumatic stress symptoms. Indeed, PTSD is a prevalent and serious residual effect of exposure to violence in tribal communities.


Cardiovascular disease (CVD) has been concluded to be higher among Native American men living on tribal lands when compared to men in other populations (Sawchuk et al., 2005). When researchers have examined factors that correlate to CVD, only exposure to violent traumatic stressors and subsequent traumatic stress symptoms have been significantly correlated to increased likelihood for CVD. General stress and the presence of depression do not account for the same variance on CVD as traumatic stress (Sawchuk et al., 2005). It is possible that exposure to violence among Native American men can lead to decreased life expectancy due to serious heart conditions.


Similar to the reports of residual associations for Native American women who experience violence, Native American men living on tribal lands with a history of victimization report increased prevalence of high-risk behaviors, including substance abuse (M. C. Jones, Dauphinais, Sack, & Somervell, 1997). Because high-risk behaviors can be considered both predictive characteristics and residual effects of exposure to violence, these behaviors can seemingly serve to initiate and exacerbate violence. For example, if a Native American man abuses alcohol, effectively lowering inhibitions, he may find himself at increased risk to be subjected to a physical altercation. As a result, the man may turn to alcohol as a means to cope with reactions to the exposure to violence, creating a cycle of substance abuse that heightens the likelihood of future exposure to violence, culminating in the need for mental health care.


Barriers to Mental Health Care


Native American victims of violence are more likely than other populations to require medical care due to the severity of the sustained injuries (Bachman, Zaykowski, Lanier, Poteyeva, & Kallmyer, 2010). Because the development of PTSD is more frequent when physical trauma occurs as a result of violence (Ford et al. 2015), it is possible that Native Americans living on tribal lands are a population with an increased need for effective mental health interventions. The Indian Health Service (IHS) is the primary medical and mental health agency providing care to Native Americans on tribal lands (Katz, 2004). The IHS system has chronically reported issues with underfunding and understaffing due, in part, to legislative policies that do not allow for funds to be provided to IHS through the United States government. As a result, the care that individuals receive through the agency is often lacking in comparison to the standards of non-tribal health care agencies. Furthermore, these services are not guaranteed to those with Native American heritage, and nearly half of the low-income Native American individuals on tribal lands cannot afford health insurance (Katz, 2004). Effectively, this renders the population within tribal lands as having the highest risk for exposure to violence, yet with limited resources to treat the effects of violence.


The largest barrier to receiving mental health care in the wake of a sexual violence crisis for Native Americans living on tribal lands may be the lack of available services within a reasonable distance. Juraska, Wood, Giroux, and Wood (2014) examined 873 Sexual Assault Response Teams (SARTs) within a designated proximity to Native American lands. SARTs are teams that provide emergency mental health care and advocacy to survivors of sexual assault and are widely used in the United States on both tribal and non-tribal lands. They reported that only 30.7% of these lands fell within a 60-minute driving range from a SART or sexual assault examiner. These researchers also reported that more than two-thirds of the tribal lands in the continental United States would not be accessible to SARTs and 381 of the 605 tribal communities were left with no coverage. Considering the high level of sexual violence that has been reported on tribal lands, it appears that SARTs are not being deployed in the areas that may need mental health care and advocacy the most.


In the area of domestic violence, researchers have concluded that significant stigmas have led to underreporting of violence by women to IHS staff (Clark, 2001). Specifically, Native American women have shared with researchers that they refused to report incidents of domestic violence to IHS staff because of the manner in which the topic was addressed and fear regarding how the staff may react. Moreover, although screening for domestic violence has become commonplace among medical facilities in the United States, only 62% of the surveyed IHS facilities had protocols to screen for domestic violence (Clark, 2001). If survivors of violence do not feel safe reporting violence to their medical and mental health professionals, appropriate aid cannot be deployed to prevent the development (or exacerbation) of traumatic stress symptoms. Furthermore, it has been theorized that Native American men and women underreport violence to IHS staff because of altered perceptions as to what constitutes violence (Tehee & Esqueda, 2008). In particular, incidents that may be reported as abuse by other populations may not be severe enough to be considered reportable violence by Native American individuals living on tribal lands.


Furthermore, a general lack of multicultural competency displayed by counselors toward Native Americans appears to be a significant barrier for this population receiving adequate mental health care. Although there has been a push for increased multicultural competency in the field of counseling in the last decade (Toporek & Vaughn, 2010), educational institutions have not traditionally focused on providing counselors-in-training the capacities for effectively working with diverse cultures (Garrett & Herring, 2001; Ponterotto, Casas, Suzuki, & Alexander, 2009; Sue, Arredondo, & McDavis, 1992). Even the theories that have enjoyed the most empirical support, such as cognitive behavioral therapy, have been scrutinized for a general lack of applicability to diverse cultures (Graham, Sorenson, & Hayes-Skelton, 2013). In fact, many common therapeutic approaches may serve to further marginalize minority populations by expecting clients to conceptualize issues and develop problem-solving strategies from the dominant culture perspective (Sue & Sue, 2012).


     Even when research and educational entities commit to better competency in understanding and working with minority populations, the majority of the attention is allotted to Hispanic, Black, and Asian populations. It is theorized that these phenomena may contribute to low rates of mental health seeking behaviors and high rates of dropout from Native American clients (Garrett & Herring, 2001). Moreover, it has been theorized that counselors, due to multicultural competency deficiencies, may even reinforce continued physical and sexual violence in Native American populations by focusing only on a client’s behavioral flaws as a means of therapeutic intervention (E. Duran, Duran, Heart, & Horse-Davis, 1998). Clearly, increased efforts in training counselors to work with Native American clients are necessary to adequately provide mental health services to this high-need population.


Implications for Counselors


To summarize, Native Americans living on tribal lands are at a higher risk for exposure to violence than other populations (Wahab & Olson, 2004). Predictive characteristics associated with increased risk include low socioeconomic status (Malcoe et al., 2002), unemployment (Lester, 1995), gender (Oetzel & Duran, 2004), cultural affiliation (Yuan et al., 2006), substance abuse (Ferraro, 2008), relationship status (Roodman & Clum, 2001), history of previous exposure to violence (Bryant-Davis et al., 2009), and adverse childhood experiences (Yuan et al., 2006). Residual associations to experiencing violence on tribal lands include PTSD (Beals et al., 2013; B. Duran et al., 2009), symptoms of anxiety and depression (Bryant-Davis et al., 2009), chronic pain (Buchwald et al., 2005), substance abuse (Yuan et al., 2006), increased high-risk behaviors such as promiscuity (Hobfoll et al., 2002), suicidal ideation (Bohn, 2003), decreased communal cohesion (Matamonasa-Bennett, 2013), and cardiovascular disease (Sawchuk et al., 2005).


Barriers experienced by Native Americans living on tribal lands for obtaining mental health services have been identified as poor standards in IHS agencies (Katz, 2004), inability to access mental health crisis SARTs (Juraska et al., 2014), underreporting of violence by Native American clients (Clark, 2001), and a lack of multicultural competency displayed by counselors (Garrett & Herring, 2001). In understanding barriers faced by Native Americans living on tribal lands, counselors can make informed decisions about intervention strategies that best aid clients in overcoming these barriers. This may mean altering therapeutic intervention approaches, increasing focus on establishing positive working alliances with clients through increased cultural competency, meeting with clients in their local communities, and advocating for systemic change in governmental and mental health agencies. Working to help eliminate the barriers to obtaining mental health services among Native Americans living on tribal lands may be the difference between those who fall into the cycle of re-victimization and those who break this cycle through collaborative efforts with the counselor.


Despite the disheartening research revealing the prevalence of violence among Native Americans living on tribal lands, this phenomenon does not appear to be common knowledge or an area of passion among some mental health counselors. Without a shift in the ways counselors view and treat violence within this population, oppression which lends to violence exposure and consequent mental health issues is not likely to subside as a result of mental health intervention. In particular, mental health counselors must commit to gaining increased competency in working with Native Americans and advocate for effective and ethical therapeutic strategies.


Counseling Practice Implications

Although many clinical approaches have been reported to exhibit limited effectiveness when working with Native American populations, some researchers have attempted to expand on empirically validated approaches in order to increase the likelihood of effectiveness with this population. Bigfoot and Schmidt (2010) adapted cognitive behavioral therapy (CBT) approaches to incorporate teachings from the traditional Native American Medicine Wheel. These researchers concluded that their method of therapy was particularly beneficial for Native American children with traumatic stress symptoms. When working with Native American survivors of trauma, counselors can expand this model by incorporating the Native American Medicine Wheel throughout the cognitive restructuring process.


The Native American Medicine Wheel is comprised of four sections with various concepts dedicated to each section. The wheel symbolizes how various elements in one’s life are separate, yet interconnected. When utilizing the wheel as an intervention tool, counselors can focus on the sections dedicated to thoughts, emotions, behavior and spirituality. CBT aims to help clients identify, challenge and change dysfunctional thought patterns in order to alter emotions and behaviors. Therefore, the counselor can use the Native American Medicine Wheel as a guide to help the client conceptualize how change is created. It may be beneficial to begin by focusing on the section dedicated to spirituality in order to gain insight into the spiritual beliefs and values held by the client. The knowledge gained in this process will help the counselor to understand what spiritual practices may be incorporated into sessions. The counselor can proceed by focusing on the sections dedicated to cognition, emotion and behavior. The suggested goals for counseling sessions are provided in Figure 1.

















Figure 1. Incorporating the Native American Medicine Wheel into CBT.



As the counselor and client move through these sections, the counselor also can incorporate the other elements within each section. For example, while processing the section dedicated to emotion, the counselor can incorporate visual imagery of summer and water while practicing relaxation techniques. The counselor and client can process how the role of the teacher applies to training oneself to cope with environmental triggers. It is further suggested that the counselor find opportunities to use traditional Native American healing methods during counseling sessions such as (a) smudging, (b) using Native American symbols to represent new topics, (c) incorporating Native American languages, (d) creating visual representations using Native American art forms, (e) forming talking circles, and (f) consulting with elders in the tribal communities (Bucharski, Reutter, & Ogilvie, 2006). Counselors also should be educated on the theory of historical trauma to assist clients in understanding how the traumas of the past impact the Native American community today. Native American clients should be educated regarding how previous traumas can impact current behavior across generations (Brown-Rice, 2013).


Although several researchers have called for increased focus on spiritual exercises while working with Native American clients (Bucharski et al., 2006; Matheson, 1996), counselors must be cautious when implementing these interventions. Matheson (1996) urged non-Native American counselors to consider the difference between cultural competencies and understanding. He reported that non-Native counselors often attempt to implement a Native American spiritual exercise as the counselor understands it, which can prove to be misguided, counterproductive and offensive. Instead, it is best to collaborate with Native American clients about how an activity should be executed and seek permission to engage in the exercise with the client. This will help to account for any violations of sacred practices and saturate the power between the counselor and client. Matheson theorized that Native Americans are often turned away from counseling due to perceived power differential and lack of interdependence between the counselor and client.


There also may be environmental changes that can be incorporated into counseling that help facilitate spiritual expression when working with Native American clients. For example, counselors may decide to hold counseling sessions outside of an office setting. A counselor may take the client to a garden or observe nature while conducting counseling sessions. Moreover, a counselor may use pet therapy techniques to help Native American clients feel a connection to nature. This technique also may help clients to express empathy (Hunter & Sawyer, 2006). Again, it is best if the counselor collaborates with the client to ensure that the setting changes are congruent with the personal beliefs and values of the client.


When a high level of exposure to traumatic stressors is present, as it often is with Native American populations, a client is likely to have biological and environmental needs that supersede mental health counseling. Targeting these needs early in the counseling relationship is likely to increase the ability of the client to meet counseling objectives. B. Jones, Tilden, and Gaines-Stoner (2008) suggested a multi-modal approach to working with Native Americans living on tribal lands due to the nature of complex trauma. First, Jones suggested that counselors build the therapeutic alliance with Native American clients by demonstrating a high level of value for sharing, autonomy and informal interpersonal interaction. Second, Jones suggested that counselors be active in consulting with agencies to provide aid with substance abuse services, housing, legal assistance, transportation, childcare and job development.


Of course, a multi-modal approach would be particularly difficult to implement for Native Americans who present with substantial barriers to mental health care. Although it is crucial that the counseling field advocate for bureaucratic changes, creating a trusting and therapeutic rapport with Native American clients is the barrier that counselors must address immediately. Native Americans living on tribal lands prefer counselors who are sensitive to Native American values and use a non-directive theoretical approach to counseling (Bichsel & Mallinckrodt, 2001). This suggests that counselors who employ more directive approaches, such as the cognitive behavioral techniques previously described, may incorporate increased person-centered approaches while building the initial working alliance with Native American clients. Native Americans have reported a preference for frequent use of collaboration (Scholl, 2006) and little use of concrete advice-giving in counseling (Garrett, 2003).


Counselors can give special considerations to Native American clients when they have been exposed to sexual violence. In particular, counselors can aid these individuals in the process of identifying and challenging self-blame and shame; survivors of sexual assault report feelings of shame and self-blame at a rate of 75% (Vidal & Petrak, 2007). Perspectives of survivors have been linked to negative self-concept (Miller, Handley, Markman, & Miller, 2010) and PTSD (Ullman, Townsend, Filipas, & Starzynski, 2007). It is important to note that the relationship between self-blame and PTSD has been theorized to be mediated by negative social reactions (Ullman et al., 2007). This suggests that processing blame and taking a position of unconditional positive regard toward the client can function to decrease PTSD symptoms.


High levels of self-blame among survivors of physical and sexual violence can serve as a predictor for re-victimization. Miller, Markman, and Handley (2007) reported increased re-victimization rates among survivors of sexual assault who reported elevated levels of self-blame. These conclusions were echoed by Edwards, Kearns, Gidycz, and Calhoun (2012), who determined that women who reported high levels of self-blame were more likely to remain in an intimate relationship with perpetrators of domestic abuse. Although there is no research available regarding the role self-blame plays among Native Americans living on tribal lands, it is clear that counselors must assess for self-blame when working with this population. In order to accomplish this task, and to collect needed research data, counselors can administer the Sexual Assault Symptom Scale (SASS), which includes subscales for self-blame, disclosure shame, safety fears and depression (Ruch, Gartrell, Amedeo, & Coyne, 1991).


Directions for Future Research


In order to increase the effectiveness of counseling interventions with Native American clients, there are several areas that warrant investigation. First, researchers should gain a better understanding of the differences between Native American tribes. The rate of violence exposure between tribes varies greatly (Oetzel & Duran, 2004), with some tribal communities being less impacted. Thus, researchers should conduct a more thorough examination of the prevalence, predictive characteristics and residual associations related to exposure to violence in tribal communities to determine the practices of those with lower levels of violence. In better understanding these factors, researchers can focus their attention on specified preventative approaches utilized by these communities and guide future counseling practices.


Furthermore, researchers should devote increased efforts to collecting data on male Native American survivors of violence. Certainly, researchers have investigated assault and homicide among this population, but prevalence and residual factors related to domestic and sexual violence is lacking in the literature. Many male survivors of physical and sexual assault are hesitant to report their experiences due to social factors including (a) fear of judgment by peers, (b) fear they will not be believed, (c) fear of being labeled homosexual, and (d) concerns about counselors maintaining confidentiality (Sable, Danis, Mauzy, & Gallagher, 2006). However, it is not known what additional factors may contribute to the hesitation of Native American men to report violence. Increased knowledge in this area could have significant implications for the prevention of violence on tribal lands among men, as well as positively impact the counseling process.


The negative impact that self-blame has on survivors of trauma has been well established (Miller et al., 2010; Ullman et al., 2007). However, the impact of self-blame in the Native American community, the population most affected by exposure to violence, has not been researched. It is important for counselors to know whether the existing research on self-blame is applicable to the Native American community in order to understand whether techniques must be altered. If self-blame was determined to be more or less prevalent among this population, researchers can help instruct counselors how to alter interventions to better account for cultural factors.


Researchers should aim to better understand the barriers to Native Americans living on tribal lands in obtaining mental health services. Specifically, the interpersonal factors in seeking services, the capacity of individuals to find services, and the role of bureaucracy in limiting resources should be further investigated. Gaining a greater understanding of efficient methods of deploying mental health services to Native American populations is only beneficial if administering services is a realistic possibility. Given that Native American people have a history of being diminished and marginalized in the interest of research (Walters & Simoni, 2009), research efforts need to be conducted in a culturally appropriate and ethical manner (Brown-Rice, 2013). If the mental health community were to commit to these research endeavors, it would provide a sufficient foundation for creating changes in the effectiveness of the treatment of this highly victimized population.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.






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Adam Hardy, NCC, is a Counselor at Glory House in Sioux Falls, SD. Kathleen Brown-Rice, NCC, is an Assistant Professor at the University of South Dakota. Correspondence can be addressed to Adam Hardy, 3005 West Courtyard Lane, Sioux Falls, SD 57108,


Examining the Theory of Historical Trauma Among Native Americans

Kathleen Brown-Rice

The theory of historical trauma was developed to explain the current problems facing many Native Americans. This theory purports that some Native Americans are experiencing historical loss symptoms (e.g., depression, substance dependence, diabetes, dysfunctional parenting, unemployment) as a result of the cross-generational transmission of trauma from historical losses (e.g., loss of population, land, and culture). However, there has been skepticism by mental health professionals about the validity of this concept. The purpose of this article is to systematically examine the theoretical underpinnings of historical trauma among Native Americans. The author seeks to add clarity to this theory to assist professional counselors in understanding how traumas that occurred decades ago continue to impact Native American clients today.

Keywords: historical trauma, Native Americans, American Indian, historical losses, cross-generational trauma, historical loss symptoms


Compared with all other racial groups, non-Hispanic Native American adults are at greater risk of experiencing feelings of psychological distress and more likely to have poorer overall physical and mental health and unmet medical and psychological needs (Barnes, Adams, & Powell-Griner, 2010). Suicide rates for Native American adults and youth are higher than the national average, with suicide being the second leading cause of death for Native Americans from 10–34 years of age (Centers for Disease Control and Prevention [CDC], 2007). Given that there are approximately 566 federally recognized tribes located in 35 states, and 60% of Native Americans in the United States reside in urban areas (Indian Health Services, 2009), there is much diversity within the Native American population. Therefore, it is difficult to make overall generalizations regarding this population (Gone, 2009), and it is important to not stereotype all Native American people. Still, Native American individuals are reported as having the lowest income, least education, and highest poverty level of any group—minority or majority—in the United States (Denny, Holtzman, Goins, & Croft, 2005) and the lowest life expectancy of any other population in the United States (CDC, 2010).


To explain why some Native American individuals are subjected to substantial difficulties, Brave Heart and Debruyn (1998) utilized the literature on Jewish Holocaust survivors and their decedents and pioneered the concept of historical trauma. The current problems facing the Native American people may be the result of “a legacy of chronic trauma and unresolved grief across generations” enacted on them by the European dominant culture (Brave Heart & DeBruyn, 1998, p. 60). The primary feature of historical trauma is that the trauma is transferred to subsequent generations through biological, psychological, environmental, and social means, resulting in a cross-generational cycle of trauma (Sotero, 2006). The theory of historical trauma has been considered clinically applicable to Native American individuals by counselors, psychologists, and psychiatrists (Brave Heart, Chase, Elkins, & Altschul, 2011; Goodkind, LaNoue, Lee, Freeland, & Freund, 2012; Myhra, 2011). However, there has been uncertainty about the validity of this theory due to the ambiguity of some of the concepts with little empirical evidence (Evans-Campbell, 2008; Gone, 2009). Specifically, there has been a lack of research about how the past atrocities suffered by the Native American people are connected with the current problems in the Native American community. The intent of this article is to examine the theoretical framework of historical trauma and apply recent research regarding the impact of trauma on an individual’s physiological functioning and cross-generational transmission of trauma. Through this analysis, the author seeks to assist professional counselors in their clinical practice and future research.


Core Concepts of Historical Trauma


Sotero (2006) provided a conceptual framework of historical trauma that includes three successive phases. The first phase entails the dominant culture perpetrating mass traumas on a population, resulting in cultural, familial, societal and economic devastation for the population. The second phase occurs when the original generation of the population responds to the trauma showing biological, societal and psychological symptoms. The final phase is when the initial responses to trauma are conveyed to successive generations through environmental and psychological factors, and prejudice and discrimination. Based on the theory, Native Americans were subjected to traumas that are defined in specific historical losses of population, land, family and culture. These traumas resulted in historical loss symptoms related to social-environmental and psychological functioning that continue today (Whitbeck, Adams, Hoyt, & Chen, 2004).


Historical Losses

For the last 500 years, individuals from the dominant European cultures have engaged in behaviors that have resulted in the purposeful and systematic destruction of the Native American people (Plous, 2003). Native Americans have been subjected to traumas that have resulted in specific historical losses. These losses include loss of people, loss of land, and loss of family and culture (Brave Heart & Debruyn, 1998; Garrett & Pichette, 2000; Whitbeck et al., 2004).


The population of Native Americans in North America decreased by 95% from the time Columbus came to America in 1492 and the establishment of the United States in 1776 (Plous, 2003). This decline can be explained by two main factors: the intentional killing of Native Americans and the exposure of Native Americans to European diseases (Trusty, Looby, & Sandhu, 2002). The majority of the Native American population died due to its lack of resistance to “diseases such as smallpox, diphtheria, measles, and cholera” that Europeans brought to North America (Trusty et al., 2002, p. 7). While some of the exposure to these illnesses was unintentional on the part of the Europeans, it has been documented that many times the Native American people were purposely subjected to these diseases. In 1763, for instance, Lord Jeffrey Amherst ordered his subordinates to introduce smallpox to the Native American people through blankets offered to them (Plous, 2003).


This loss of population further impacted the Native American community due to the lack of public acknowledgment of these deaths by the dominant culture and the denial of Native Americans to properly mourn their losses. Mourning practices were disrupted when an 1883 federal law prohibited Native Americans from practicing traditional ceremonies (Brave Heart, Chase, Elkins, & Altschul, 2011). This law remained in effect until 1978, when the American Indian Religious Freedom Act was enacted. This disenfranchised grief has resulted in the Native American people not being able to display traditional grief practices (Brave Heart et al., 2011; Sotero, 2006). As a result, subsequent generations have been left with feelings of shame, powerlessness and subordination (Brave Heart & DeBruyn, 1998).


The taking of Native American lands was a primary agenda for the majority of the United States government officials in the 19th century (Duran, 2006; Sue & Sue, 2012). President Andrew Jackson approved the Indian Removal Act of 1830, initiating the use of treaties in exchange for Native American land east of the Mississippi River and forcing the relocation of as many as 100,000 Native Americans (Plous, 2003). The motivation for the confiscation of the lands was often driven by economics (e.g., Fort Laramie Treaty of 1868; Trusty et al., 2002). By 1876, the U.S. government had obtained the majority of Native American land and the Native American people were forced to either live on reservations or relocate to urban areas (Brave Heart & Debruyn, 1998; Trusty et al., 2002). Reservations, for the most part, were not the best lands for agriculture and hunting. Further, being relocated to urban areas removed Native American people from all the lives they were familiar with. Leaving their domestic lands led to a decline in socioeconomic status as Native American men were not able to provide for their families, and the families became dependent on goods provided by the U.S. government (Brave Heart & Debruyn, 1998). These relocations resulted in the death of thousands of Native Americans and the disruption of families.


The agenda throughout the majority of history by U.S. government agencies, churches, and other organizations was to encroach on the Native American population and lands, leading to a disruption to the Native American culture for the preponderance of the Native population (Brave Heart & DeBruyn, 1998; Garrett & Pichette, 2000). Principally, the intent was to force the Native American people to fully assimilate to the dominant European-American culture and completely abandon their own culture. In 1871 the U.S. congress declared Native Americans wards of the U.S. government, and the U.S. government’s goal became to civilize Native Americans and assimilate them to the dominant White culture (Trusty et al., 2002). Government and church-run boarding schools would take Native American children from their families at the age of 4 or 5 and not allow any contact with their Native American relations for a minimum of 8 years (Brave Heart & Debruyn, 1998; Garrett & Pichette, 2000). In the boarding schools, Native American children had their hair cut and were dressed like European American children; additionally, all sacred items were taken from them and they were forbidden to use their Native language or practice traditional rituals and religions (Brave Heart & Debruyn, 1998; Garrett & Pichette, 2000). Many children were abused physically and sexually and developed a variety of problematic coping strategies (e.g., learned helplessness, manipulative tendencies, compulsive gambling, alcohol and drug use, suicide, denial, and scapegoating other Native American children) (Brave Heart & Debruyn, 1998; Garrett & Pichette, 2000). Such circumstances led many Native Americans to not engage in traditional ways and religious practices, which led to a loss of ethnic identity (Garrett & Pichette, 2000). The removal of children from their families is considered one of the most devastating traumas that occurred to the Native American people because it resulted in the disruption of the family structure, forced assimilation of children, and a disruption in the Native American community. This situation is considered the crucial precursor to many of the existing problems for some Native Americans (Brave Heart & Debruyn, 1998; Duran & Duran, 1995).


Historical Loss Symptoms

The second core concept of the theory of historical trauma relates to the current social-environmental, psychological and physiological distress in Native American communities, in that these difficulties are a direct result of the historical losses this population has suffered. Specifically, these traumatic historical losses result in historical loss symptoms.


     Societal-environmental concerns. Domestic violence and physical and sexual assault are three-and-a-half times higher than the national average in Native American communities; however, this number may be low, as many assaults are not reported (Sue & Sue, 2012). Cole (2006) proposed that the breakdown in Native American families due to the forced removal of Native American children can be seen as the reason for the high number of child abuse and domestic violence incidents reported in these families. Additionally, Native American children are one of the most overrepresented groups in the care of child protective services (Hill, 2008). Further, fewer Native Americans have a high school education than the total U.S. population; an even smaller percentage has obtained a bachelor’s degree: 11% compared with 24% of the total population. Almost 26% of Native Americans live in poverty compared to 12% for the entire U.S. population (U.S. Census Bureau, 2006). Native Americans residing on reservations have double the unemployment rate compared to the rest of the U.S. population (U.S. Census Bureau, 2006).


     Psychological concerns. Native Americans have the highest weekly alcohol consumption of any ethnic group (Chartier & Caetano, 2010). Native American adults reported that in the last 30 days, 44% used alcohol, 31% engaged in binge drinking, and 11% used an illicit drug (National Survey on Drug Use and Health, 2010). Many Native American adolescents have co-occurring disorders related to substance abuse and mental health disorders (Abbott, 2006). Abuse of alcohol by Native individuals may be related to low self-esteem, loss of cultural identity, lack of positive role models, history of abuse and neglect, self-medication due to feelings of hopelessness, and loss of family and tribal connections (Sue & Sue, 2012).


Statistics indicate that a proportionally high level of Native Americans have mood disorders and posttraumatic stress disorder (PTSD; CDC, 2007; Dickerson & Johnson, 2012). Suicide rates among Native Americans are 3.2 times higher than the national average (CDC, 2007). For males ages 15–19, Native American suicide rates were 32.7 per 100,000, compared to non-Hispanic White (14.2), Black (7.4), Hispanic (9.9), and Asian or Pacific Islander (8.5) [CDC, 2007]. Studies have shown family disruptions and loss of ethnic identity places Native American adolescents at higher risk for alcoholism, depression and suicide (May, Van Winkle, Williams, McFeeley, DeBruyn, & Serma, 2002). It has been found that an increase in the number of suicides corresponds to a lack of linkage between the adolescents and their cultural past and their ability to relate their past to their current situation and the future (Chandler, Lalonde, Sokol, & Hallet, 2003).


     Physiological concerns. The life expectancy at birth for the Native American population is 2.4 years less than that of all U.S. populations combined (CDC, 2010). Further, Native American individuals are overrepresented in the areas of heart disease, tuberculosis, sexually transmitted diseases, and injuries with, diabetes being more prevalent with this population than any other racial or ethnic group in the United States (Barnes et al., 2010). Only 28% of Native Americans under the age of 65 have health insurance (CDC, 2010).


The majority (60%) of Native Americans receive behavioral and medical health services from Indian Health Services (IHS, 2013a). IHS was established and funded by the U.S. government in 1955 to uphold treaty obligations to provide healthcare services to members of federally recognized Native American tribes (Jones, 2006). Three branches of service exist within IHS: (a) an independent, federally operated direct care system, (b) tribal operated health care services, and (c) urban Indian health care services (Sequist, Cullen, & Acton, 2011). However, according to the IHS (2009), the Native American people “have long experienced lower health status when compared with other Americans.” This is substantiated by the IHS (2013a) report that $2,741 is spent per IHS recipient in comparison to $7,239 for the general population; of that, less than 10% of these funds were utilized for mental health and substance abuse treatment in 2010 even though the rates of mental health and substance abuse issues are prominent. This disparity in medical and behavioral health services is due to “inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences” (IHS, 2013b). Further, Barnes and colleagues (2010) reported that the inequality may not only be related to the above factors, but epigenetic and behavioral influences. There may be environmental factors that alter the way genes are expressed (Francis, 2009) and behavioral patterns that further negatively influence the situation. In order to gain a better understanding of relationship epigenetic component, it is important to recognize how trauma impacts a person’s physical as well as mental functioning.



The Impact of Trauma on Physiological Functioning


“Traumatic experiences cause traumatic stress, which disrupts homeostasis” in the body (Solomon & Heide, 2005, p. 52). People who have experienced traumatic events have higher rates than the general population for cardiovascular disease, diabetes, cancer and gastrointestinal disorders (Kendall-Tackett, 2009). Specifically, trauma affects the functioning of the sympathetic nervous system and the endocrine system (Solomon & Heide, 2005). When the body is experiencing stress, it needs oxygen and glucose in order to fight or flee from the perceived danger. The brain then sends a message to the adrenal glands telling, them to release epinephrine (Kendall-Tackett, 2009). Epinephrine increases the amount of sugar in the blood stream, increases the heart rate and raises blood pressure. The brain also sends a signal to the pituitary gland to stimulate the adrenal cortex to produce cortisol that keeps the blood sugar high in order to give the body energy to be able to escape the stressor (Solomon & Heide, 2005). This physiological response to stress is created for a short-term remedy. Additionally, it has been found that in people who have experienced a prior trauma, their bodies react quicker to new stressors and thus cortisol and epinephrine are released at a faster rate (Kendall-Tackett, 2009).


Amygdala and Hypothalamic-Pituitary-Adrenal Axis

     Experiencing trauma can impact a person’s neurological functioning. After a traumatic event, many people have an overactive amygdala (Brohawn, Offringa, Pfaff, Hughes, & Shin, 2010). This hyperactivation of the amygdala “may be responsible for symptoms of hyperarousal in PTSD, including exaggerated startle responses, irritability, anger outbursts, and general hypervigilance,” and may be the reason for a person re-experiencing the event due to a trauma reminder (Weiss, 2007, p. 116). After the original trauma takes place, any perceived external threat that reminds the body of the original trauma (e.g., sound, face, smell, gesture) will cause the body, through the amygdala, to automatically respond to the perceived threat by producing epinephrine and cortisol (Weiss, 2007). This biological response happens without the person consciously being aware of it. It has been found that “emotionally arousing stimuli are generally better remembered than emotionally neutral stimuli, and the amygdala is responsible for this emotional memory enhancement” (Koenigs & Grafman, 2009, p. 546). The amygdala is responsible for giving emotional meaning to the external stimuli; however, the hippocampus provides contextual meaning to the stimuli (Brohawn et al., 2010).


Ganzel, Casey, Glover, Voss, and Temple (2007) examined whether trauma exposure has long-term effects on the brain and behavior in healthy individuals. These researchers compared a group of people who lived within 1.5 miles of the World Trade Center on 9/11 (Ground Zero) and a group of people who lived 200 miles away from Ground Zero. More than three years after the events of 9/11, both groups were shown pictures of fearful and calm faces; the amygdala activation of the group members was measured utilizing functional Magnetic Resonance Imaging (fMRI; Ganzel et al., 2007). The results indicated that the group that resided closer to Ground Zero had heightened amygdala reactivity when shown images of people in fear.


In another study, researchers utilized fMRI to examine amygdala and hippocampus activation in 18 trauma-exposed non-PTSD control subjects and 18 individuals with PTSD (Brohawn et al., 2010). The results of this study indicated that there was hyperactive amygdala activation when negative emotional stimuli were introduced to the PTSD group. Additionally, when a person is exposed to traumatic events during development, the hypothalamic-pituitary-adrenal (HPA) axis can be altered, which may increase susceptibility to disease, including PTSD and other mood and anxiety disorders (Gillespie, Phifer, Bradley, & Ressler, 2009). The HPA axis is the part of the neuroendocrine system that controls reactions to stress as well as regulates digestion, the immune system, mood and emotions, and sexuality. This overactivation of the amygdala and HPA axis due to re-experiencing the initial trauma sends the message to the adrenal glands to release epinephrine and cortisol (Kendall-Tackett, 2009; Solomon & Heide, 2005). Current research has shown that the continual release of cortisol due to exposure to recurrent stressors, particularly during development, can cause the HPA axis to shutdown, which results in low cortisol levels (Neigh, Gillespie, & Nemeroff, 2009). Therefore, chronic exposure to stressors can relate to either a hypo- or hyper-stress response in the HPA axis.


This impact on the HPA axis functioning may explain why researchers have found a relationship between PTSD and physical illnesses. Weisberg et al. (2003) performed a study of 502 adults; 17% had no history of trauma, 46% had a history of trauma but no PTSD, and 37% were diagnosed with PTSD. The researchers found that individuals with PTSD reported a significantly larger number of current and lifetime medical conditions than did other participants, including anemia, arthritis, asthma, back pain, diabetes, eczema, kidney disease, lung disease, and ulcers (Schnurr & Green, 2004; Weisberg et al., 2003). Specifically, a multiple regression indicated that PTSD was a stronger predictor of medical difficulties than physical injury, lifestyle factors, or comorbid depression (Weisberg et al., 2003). A study of veterans found that those participants with PTSD were more likely to have the medical conditions of osteoarthritis, diabetes, heart disease, comorbid depression, and obesity (David, Woodward, Esquenazi, & Mellman, 2004). Additionally, Goodwin and Davidson (2005) conducted a survey study of over 5,500 subjects and found that there was an association between a diagnosis of diabetes and having PTSD.


Integrating Historical Trauma Theory   


As evidenced above, the traumas inflicted on the Native American people (historical losses) are well documented and the literature provides significant information regarding the current psychological, environmental-societal, and physiological problems facing the Native American people (historical loss symptoms). The literature also supports the conceptualization of a relationship between experiencing trauma and the brain remembering the trauma when confronted by an emotional meaning stimulus (Brohawn et al., 2010; Weiss, 2007). Further, a relationship between PTSD and physiological functioning has been found (David et al., 2004; Weisberg et al., 2003). Therefore, it can be surmised that, given the substantial historical traumas Native Americans have experienced, they would be at greater risk of developing physical and emotional concerns related to re-experiencing these traumas. However, the question remains whether some Native American people are being confronted by emotionally significant stimuli in the present day that causes them to reflect about the historical traumas that occurred many generations ago.


In answer to this question, Whitbeck and colleagues (2004) developed the Historical Loss Scale and the Historical Loss Associated Symptoms Scale. Whitbeck et al. (2004) surveyed Native American adult parents of children for their perceptions of historical events. These participants were generations removed from many of the historical traumas that had been inflicted on the Native American people. However, 36% had daily thoughts about the loss of traditional language in their community and 34% experienced daily thoughts about the loss of culture (Whitbeck et al., 2004). Additionally, 24% reported feeling angry regarding historical losses, and 49% provided they had disturbing thoughts related to these losses. Almost half (46%) of the participants had daily thoughts about alcohol dependency and its impact on their community. Further, 22% of the respondents indicated they felt discomfort with White people, and 35% were distrustful of the intentions of the dominant White culture due to the historical losses the Native American people had suffered (Whitbeck et al, 2004).


Ehlers, Gizer, Gilder, Ellingson, & Yehuda (2013) utilized the Historical Loss Scale and Historical Loss Associated Symptoms Scale to survey 306 Native American adults. The majority of the participants thought about historical losses at least occasionally and these thoughts caused them distress. In particular, how frequent a person thought about historical losses was linked with not being married, high degrees of Native heritage and cultural identification. When comparing the Whitbeck et al. (2004) and Ehlers et al. (2013) studies, about the same percentage of participants thought about the losses several times a day; however, respondents reported less daily and weekly thoughts of historical losses in the Ehlers et al. (2013) results. The differences between the two studies could be a result of “the extent of historical losses suffered by each individual Native community, the impact of current trauma, levels of acculturation, population norms about historical losses, and population admixture” (Ehlers et al., 2013, p. 6). Therefore, it is important to recognize there are differences in how historical losses are impacting Native American communities.


The above findings may clarify one reason why some populations in the Native American community are suffering from such severe emotional, physical and social-environmental consequences related to past traumas. Specifically, their bodies’ ability to deal with stress has been overwhelmed by the reoccurring thoughts related to historical losses they have suffered. However, it is important not to make generalizations and to remember not all of the Native American people have been experiencing severe historical loss symptoms (Evans-Campbell, 2008). These within-group differences in the Native American population would explain the variances in rates of disease, child abuse and neglect, violence, suicide, unemployment, familial disruption, and poverty between tribal affiliations.


Another important consideration is an individual’s perception of being discriminated against. Perceived discrimination has been associated with negative health consequences (Bogart, Wagner, Galvan, Landrine, Klein, & Sticklor, 2011). In particular, Capezza, Zlotnick, Kohn, Vicente, and Saldivia (2012) administered structured diagnostic assessments for major depressive disorder (MDD) and PTSD and the Alcohol Use Disorders Identification Test (AUDIT) to 2,839 participants in Concepción and Talcahuano, Chile. These researchers found that controlling for demographic variables and previous trauma, participants who reported discrimination in the preceding six months were significantly more likely to participate in risky alcohol use, illegal drug use, and be diagnosed with MDD and PTSD than respondents not reporting discrimination.


Another study examined the relationships between neglect and abuse, PTSD symptoms, ethnicity-specific factors (e.g., ethnic orientation, ethnic identity, perceived discrimination), and alcohol and drug problems within adolescent girls (Gray & Montgomery, 2012). These researchers found that abuse and neglect were correlated to alcohol and drug problems, but only in relation with PTSD symptoms. It also was found that greater perceived discrimination was related with an increased influence of abuse and neglect on PTSD symptoms (Gray & Montgomery, 2012). Given the generations of persecution, discrimination, and oppression suffered by the Native American people (Brave Heart et al., 2011), it is reasonable that perceived discrimination could be an aggravating factor.


Cross-Generational Trauma Transmission


As a result of the loss of people, land, and culture, a systematic transmission of trauma to subsequent generations occurred that has resulted in historical loss symptoms for many Native American individuals (Brave Heart et al., 2011; Whitbeck et al., 2004). Specifically, the traumatic events suffered during previous generations creates a pathway that results in the current generation being at an increased risk of experiencing mental and physical distress that leaves them unable to gain strength from their indigenous culture or utilize their natural familial and tribal support system (Big Foot & Braden, 2007). Therefore, the next step in investigating the theory of historical trauma is to understand how the generational transmission of trauma transpires. Significant research has been completed on the cross-generational transmission of trauma regarding Holocaust victims and their descendants (Doucet & Rovers, 2010; Jacobs, 2011; Neigh et al., 2009; Yehuda, Schmeidler, Wainberg, Binder-Brynes, & Duvdevani, 1998).


Based upon this research, three means by which trauma is transmitted to subsequent generations have been identified: (a) children identifying with their parents’ suffering, (b) children being influenced by the style of communication caregivers use to describe the trauma, and (c) children being influenced by particular parenting styles (Doucet & Rovers, 2010). Parental identification is a form of vicarious learning in which the child identifies with trauma and takes on the historical loss symptoms. Lichenstein and Annas (2000) found there is a relationship between a parent having a fear and children developing the same fear due to vicarious learning. This seems to be substantiated by Myhra’s (2011) findings that all 13 participants in a qualitative study examining the relationship between substance use and historical trauma in Native American adults believed that historical trauma was key to their elders’ dysfunctional behavior—in particular, substance abuse. One participant characterized it as “monkey see, monkey do,” in that she was following her family’s pattern of abusing substances and being involved in abusive interpersonal relationships (Myhra, 2011, p. 26). However, it is important to mention that participants also expressed a great respect and admiration for their elders due to their strength and resiliency.


Lichenstein and Annas (2000) also examined if the way parents relayed information to children regarding a stimulus impacted the development of a fear or phobia in the children. The researchers found that there was a relationship between children developing a fear or phobia when parents engaged in negative talk with children regarding the stimulus. In the Native American culture, information and history is often passed down from generation to generation in a narrative summary. Given that the atrocities that were inflicted on the Native American people were substantive, it seems understandable that transmission of historical loss symptoms could occur via this pathway to the children. In fact, Myhra (2011) found that Native American participants connected “the impact of elders’ stories of historical trauma and loss, and their own traumatic experiences, to intrusive thoughts about these ordeals and to fear that trauma will continue for future generations” (p. 25).


Parenting style also can be impacted as a result of trauma. Walker (1999), in completing an extensive literature review of this subject, found that parenting can be impacted as a result of the parental exposure to trauma. First, parents may have difficulty with trust and intimacy as a result of their experiences of being victimized. Therefore, it may be a challenge for them to develop a healthy attachment with their children. Second, many adults who have been subjected to abuse and neglect may in turn unintentionally enter into a cycle of violence with their own children (Walker, 1999). Due to the forced removal of Native children from their homes and tribal communities, the familial structure was interrupted and many suffered extreme abuse and neglect (Cole, 2006). Therefore, subsequent generations of Native Americans may have not been able to develop healthy parenting styles and inadvertently continued a cycle of violence and abuse. A relationship between a parent’s diagnosis of PTSD and abuse and neglect of children also has been found. Children of Holocaust survivors diagnosed with PTSD report more neglect and emotional abuse than demographically similar children of parents who were not diagnosed with PTSD (Neigh et al., 2009; Yehuda, Bierer, Schmeidler, Aferiat, Breslau, & Dolan, 2000). The reasons why Native American children stand overrepresented in the U.S. foster care system (Hill, 2008) may be related to the abuse suffered by many Native Americans while in boarding schools and the high number of Native Americans displaying PTSD symptoms.


As mentioned previously, experiencing traumatic events during development can alter the HPA axis, which may increase susceptibility to disease (e.g., PTSD, mood and anxiety disorders) (Gillespie et al., 2009). Specifically, it has been found that children of Holocaust survivors have significantly lower cortisol levels when compared with control groups (Yehuda et al., 2000). Further, children of parents who developed PTSD after surviving the Holocaust had reduced cortisol levels when compared to children of Holocaust survivors that did not have PTSD. The results of this study provide that trauma exposure can change how the HPA axis functions and increase risk of PTSD symptoms at least one generation removed from the initial trauma experience (Neigh et al., 2009; Yehuda et al., 2000).


Other studies have found that adult children of Holocaust survivors have a greater lifespan occurrence of PTSD, as well as other mood and anxiety disorders, than demographically comparable individuals who reported a similar exposure to trauma (Neigh et al., 2009; Yehuda et al., 1998). Further, children of trauma-exposed Holocaust survivors who did not develop PTSD were at an increased risk of manifesting other mental health disorders (e.g., depression, anxiety, PTSD) when compared to individuals whose parents were not exposed to trauma (Yehuda, Halligan, & Bierer, 2001). Additionally, researchers have looked at the impact of maternal trauma on the unborn child. Nine-month-old infants born to mothers who were diagnosed with PTSD as a result of trauma-exposure related to the September 11, 2001 attacks had lower cortisol levels than infants born to unexposed mothers (Neigh et al., 2009; Yehuda et al., 2005). The results were more significant with infants whose mothers were in their third trimester when the attacks occurred.


Based upon the above cited research, it can be surmised that parents’ exposure to trauma does form a passageway to subsequent generations that results in an increased risk of negative mental health symptoms. In fact, the latest version of the American Psychiatric Association (APA, 2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes a stressor criterion for adults, adolescents, and children older than six years related to learning that a close relative or close friend was exposed to trauma. Additionally, the DSM-5 added a PTSD diagnosis for a child six years or younger. One of the triggering events is a child learning that a traumatic event has occurred to a parent or caregiving figure (APA, 2013).


Implications for Professional Counselors


The results of this analysis of historical trauma assist in removing some of the ambiguity regarding this theory. Specifically, a link between neurological functioning and trauma and cross-generational trauma transmission were conceptualized and applied to the theory of historical trauma. This comprehensive examination provides professional counselors with an increased understanding of how traumas that occurred within the Native American population generations ago continue to impact clients today. This information is critical to enhance clinicians’ clinical skills when working with Native American clients. Having an understanding of historical trauma will assist professional counselors in being more responsive to the unique needs of members of this population and incorporating historical trauma in their clinical work.


Dionne, Davis, Sheeber, and Madrigal (2009) provide that integrating mainstream mental health intervention in Native American individuals should involve two phases: (a) motivational phase (i.e., historical context around current difficulties in Native American communities is discussed); and (b) intervention phase (i.e., utilizing mainstream evidence-based interventions). Not only do clinicians and interventions need to be culturally competent, but conventional counseling theories need to be adjusted to be culturally appropriate (Wendt & Gone, 2012). Thus, traditional counseling theories should be integrated with elements of historical trauma and the Native American holistic view of the person.


First, professional counselors should reframe historical loss symptoms in terms of collective responses that are employed to assist clients in alleviating symptoms (Brave Heart & DeBruyn, 1998). Thus, the psychological, social-environmental, and physiological concerns that plague many Native people are signs and symptoms of a communal reaction to generations of persecution, discrimination, and oppression. Specifically, historical trauma differs from the diagnosis of PTSD in that many of the traumas that occurred were systemic in nature (e.g., massacres, Trail of Tears, mass removal of children), which led to collective subjugated grief. Brave Heart and DeBruyn (1998) in their pioneering writings on historical trauma proposed that the initial disenfranchised grief of the Native American people resulted in historical unresolved grief. Therefore, a second intervention is the need for clinicians to validate the existence of not only the initial historical losses that occurred but the continued discrimination and oppression that has impacted the Native American people (Brave Heart et al., 2011). Therapeutic change may be difficult for Native American clients to engage in without validation of not only the past atrocities that occurred to Native American communities, but acknowledgment of the current discriminatory environment that many Native people still endure. Given that the dominant European culture has been the perpetrator of many of the historical losses, this validation is especially important when the professional counselor is a member of the White dominant culture. Third, clients should be educated regarding historical trauma to enhance awareness about its impact and the associated grief and loss that can occur (Brave Heart & DeBruyn, 1998). The Native American people are well aware of the history of the traumas of their people; however, they might not have insight about how the events of the past may impact them today.


Finally, professional counselors need to understand that historical trauma permeates all domains of existence (e.g., personal identity, interpersonal relationships, collective memory, cultural and spiritual worldviews; Weisband, 2009). Clinicians need to have knowledge that historical losses impact all facets of a client. This can be explained to the client by use of the Medicine Wheel Model of Wellness, Balance, and Healing (The Medicine Wheel). According to this model, a person is interconnected through the spiritual, physical, emotional and mental. The Medicine Wheel has been found to be an effective tool in working with Native American individuals (Gray & Rose, 2012).


Implications and Directions for Future Research


This article provides needed insight regarding historical trauma; however, future research regarding this concept is needed, as Native Americans are underrepresented in mental health research (Echo-Hawk, 2011). Gone and Alcántara (2007) completed an extensive review of the literature on evidence-based mental health interventions with Native Americans and found 3 randomized or controlled outcome studies, 6 nonrandomized or uncontrolled outcome studies, 16 studies related to intervention descriptions, 7 clinical case studies, and 24 intervention approaches. The majority of these articles did not address assessment of therapeutic outcomes, but were more theoretically based or provided recommendations for working with Native American clients. The 9 outcome studies described pre- and post-intervention results for a treatment group with no control group for comparison, leaving questions about the validity of the treatment intervention. Specifically, there is no proven empirically based treatment modality to utilize when addressing the distinctive mental health needs of Native American clients. Given the severe mental health problems that plague many of the Native American people, determining effective psychological treatments is vital (Gone & Alcántara, 2007). This can be accomplished through future empirical research.


However, the Native people have a history of being devalued and marginalized in the interest of research (Walters & Simoni, 2009). Therefore, research should be conducted in a culturally sensitive and ethical manner. This is best accomplished by utilizing a collaborative approach (Waiters & Simoni, 2009). Therefore, researchers should work in partnership with tribal elders, healers, officials, health administrators and mental health providers. Specifically, future research should utilize a collective approach and take into account the diversity in tribal affiliations of clients (Hartmann & Gone, 2012).


The first area in need of research attention relates to the fact that the majority of the scholarship on historical trauma has been theoretical in nature. Therefore, there is a need to have empirical evidence to substantiate this concept. First, beneficial research would demonstrate a relationship between individuals reflecting on their historical losses (e.g., loss of people, land, family and culture) and suffering from historical loss symptoms (e.g., psychological distress, social-environmental problems, physiological concerns). Given that Whitbeck and colleagues (2004) have created scales to measure historical trauma, other self-report measures (e.g., depression, anxiety, self-efficacy inventories) could be utilized to determine a relationship between positive and negative affect and a person’s degree of historical trauma. Second, this author suggests that the previous research regarding the impact of trauma on physiological functioning can be a catalyst for future research on historical trauma. Specifically, future studies can focus on determining if there is a correlation between neural activity and clients’ self-reported level of historical trauma. In these studies, fMRI technology and Whitbeck et al. (2004) scales can be utilized to determine the relationship between clients’ self-reported level of historical trauma and amygdala and hippocampus activity.


The second area of research should examine the effectiveness of incorporating indigenous healing methods with mainstream counseling approaches. Utilizing a collaborative approach, researchers would utilize the expertise and guidance of culture keepers (e.g., tribal elders, traditional healers) (Hartmann & Gone, 2012) to incorporate indigenous healing methods with mainstream counseling theories. Given that no evidence-based treatment modality has been established for clinicians to utilize when treating Native American clients, additional research in this area is crucial. This article provides clarity on the theory of historical trauma, but there is a need for empirical research in order to improve the understanding of how atrocities perpetuated on the Native American people generations ago continue to manifest today by psychological, social-environmental and physiological means.




Large numbers of the Native American population continue to suffer from severe psychological, economic, social, environmental and physical distress. The theory of historical trauma provides professional counselors a framework to understanding the current issues that are invading the Native American people and their culture. Specifically, practitioners working with this population should have an understanding of how the historical losses suffered generations ago have resulted in historical loss symptoms being transferred to subsequent and current generations of Native Americans. The concept of historical trauma is “collective and multilayered rather than being solely centered on an individual” and this differs from a “typical Eurocentric perspective of illness and treatment, which tends to reduce suffering to discrete illnesses with individual causes and solutions” (Goodkind, Hess, Gorman, & Parker, 2012, p. 1021). Therefore, professional counselors should adapt evidence-based practices by applying tribal-specific healing strategies, community support, and approaches that incorporate validation of grief and loss associated with historical traumas (Brave Heart et al., 2011). Failure of professional counselors to deepen their understanding of this population would continue the disparity of Native clients receiving competent behavioral health services and facilitate the continuation of the cycle of historical trauma to future generations.







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Kathleen Brown-Rice, NCC, is an Assistant Professor at the University of South Dakota. Correspondence can be addressed to Kathleen Brown-Rice, Division of Counseling and Psychology in Education, School of Education, University of South Dakota, 210E Delzell, Vermillion, SD 57069,