In the 2000 Census, about 4.3 million people, or 1.5% of the total United States population, defined themselves as American Indian or Alaskan Native. This number includes people who were living on tribal lands as well as those living in rural, suburban, and urban areas unassociated with an American Indian or Alaskan Native (AI/AN) tribe. Some claimed heritage in multiple tribes or no specific tribe and a significant percent (43%) listed other ethnic or racial identities in combination with AI/AN (Ogunwole, 2006). Because of this diversity, some researchers (see Webb, J.P. and Willard, W., 1975) claim that an analysis of AI/AN experience as a whole in relation to issues such as suicide is misguided and unscientific. However, I take the position that there exist commonalities within this diversity, especially with regard to the effects of acculturation and assimilation among AI/AN people. With this understanding and perspective, while respecting individual differences, I will approach the issue of suicide among American Indian and Alaskan Native people.
The AI/AN population experiences a high rate of suicide, especially among adolescents. Until recently, few people recognized the problem or attempted to find an answer to the daunting question of why suicide rates are disproportionately high among AI/AN people compared to the general population. In the belief that a more complete understanding of suicide from proximate to ultimate causes will better inform intervention programs, this paper will examine individual risk factors and environmental influences, ultimately focusing on the effects of historical trauma and current acculturation.
A brief overview of the suicide epidemiology among AI/AN people will provide a basic understanding of the extent of the problem. According to data from 2006, approximately 30% of American Indian youth living on or near reservations had considered or attempted suicide, a rate about 2.5 times higher than that of the general population for the same age group (Tirado, 2006). Furthermore, suicide, at a rate of 37.1 deaths/100,000, is the second leading cause of death among AI/AN youth age 15-24 (Wissow, 2000). A few general trends characterize suicide among American Indians. Adolescent males have the highest rates of suicide and the methods used, such as firearms and hanging, are often highly lethal. In addition, a larger proportion of AI/AN suicides are alcohol related than in the general population. There is also some indication that suicide rates may vary based on certain tribal conditions; tribes that are going through rapid acculturation and change in traditional systems experience higher rates of suicide (May, 1987).
The most proximate causes of suicide involve risk factors, such as mental illness and drug abuse, which have been identified in multiple studies and are often prevalent among American Indian and Alaskan Native people. Many of these risk factors signify a departure from healthy development within an individual. Among AI/AN people, rates of mental illnesses which are risk factors for suicide, including depression (19%), bipolar disorder (7.6%) and Post-Traumatic Stress Disorder (15%) are all higher than among the general population. Drug and alcohol abuse, which is often found in combination with mental illnesses, is an additional risk factor for suicide. Illicit drug use rates are about twice as high in AI/AN people (12.6%) as in the general population (6.4%) (Tirado, 2006). Among AI/AN youth, moderate risk drug use varies between 20-40% and high risk drug use varies between 10-25% (Beauvais et al, 2004). Alcohol abuse is also more widespread among AI/AN people and exposure to alcohol occurs at an earlier age than among the general population. The rates of arrest for alcohol related crimes, including drunkenness, violation of liquor laws, and driving under the influence are also higher for AI/AN people (Perry, 2004). Though significant tribal variation exists, these numbers indicate that there are unaddressed mental and physical health problems among AI/AN people.
Damaging social interactions constitute another category of risk factors, including intrapersonal or family conflict, perceived discrimination and physical or sexual abuse. For example, in Southwest and Northern Plains tribes, rates of physical abuse were more than twice as high as the general population and were also correlated with mental illness (Libby et al., 2005). Therefore, in some communities, the experience of these detrimental social interactions may contribute to the high suicide rates. Among the many risk factors for suicide, some do not fit into the aforementioned categories but are still important when evaluating an individual. These include a previous suicide attempt, suicide of friend or relative, a traumatic life event, and availability of means for suicide. All of the risk factors interact with each other to influence suicide risk and it can be difficult or even undesirable to attempt to address them individually. A study by the Indian Health Service found that three out of four AI/AN youth who had three or more risk factors and no protective factors had attempted suicide (Tirado, 2006). The accumulation of risk factors therefore contributes to high suicide rates.
The general strain theory has been used as a framework for evaluating adolescent suicide among AI/AN people and is helpful in understanding the interaction between risk factors. In the general strain theory, the accumulation of stressors leads to negative states which then results in the destructive behavior, in this case suicide. An evaluation of the strain theory applicability to an American Indian tribe found that the stressors of rejection by a guardian, being verbally abused by a guardian, having negative attitudes towards school, and experiencing discrimination were all associated with increased suicide risk. However, though these factors were associated with suicide they also produced negative emotions of anger and depression which were themselves associated with suicide. Depression, self-directed emotion was more closely correlated with suicide risk than anger, outward directed emotion. The general strain theory is important in that it demonstrates the importance of underlying factors in producing negative emotions which lead to suicide rather than focusing only on the most proximate cause; the negative emotion(Walls et al., 2007).
The literature largely focuses on the risk factors for suicide and their high prevalence among AI/AN people but it is important to question why these rates are so high compared to the general population. One explanation, supported by the 2000 Census, is that AI/AN people tend to live in environments which can lead to the accumulation of multiple risk factors. Compared to the general population, AI/AN people have a higher poverty rate (25.7%) and higher unemployment. AI/AN suicide rates have been linked with high poverty rates and poverty has been linked with many other risk factors including poor physical and mental health, family conflict, violence and alcohol abuse (Leach, 2006). A lower percentage of AI/AN people (71%) have completed high school education or received a bachelors degree (11%) than the general population and this disparity is more pronounced for those living on tribal lands than for all AI/AN people (Ogunwole, 2006). In addition, 101 out of 1000 AI/AN people experience a violent crime every year, compared to 41 out of 1000 people in the general population, and this difference is even more significant in rates of simple and aggravated assault (Perry, 2004). Environmental influences such as poverty, lack of education, and violent crime may all increase the prevalence of many risk factors for suicide among AI/AN people.
The effect of colonization and of the trauma inflicted upon AI/AN communities is another potential difference between the experiences of AI/AN people and the general population which may influence suicide rates. The majority of AI/AN tribes and traditions remaining today originated in a time period prior to extensive European contact, though considerable variation exists in the circumstances and time of contact between individual AI/AN tribes and Europeans. Time of contact up to approximately 1890 encompasses the period in which Christianity, foreign diseases, the establishment of reservations and the loss of native land significantly impacted AI/AN life. During the following period, from about 1890 to 1970, many AI/AN people were forced to assimilate into the culture of the United States. Reservation lands were lost and the previous occupants left for more urban areas (Leach, 2006). In addition, a significant portion of AI/AN children were sent to boarding schools where “education” was used as a tool to deprive them of their language and culture (Whitebeck et al., 2004). However, in a testament to their strength, many tribes managed to preserve their cultures and are currently undergoing a period of reclaiming and redefining AI/AN identity.
Through the concept of historical grief and trauma, this historical experience of genocide and ethnic cleansing can be connected to current problems, including high suicide rates. Historical grief operates on the principle that traumatic historical events can have negative effects in the present. In relation to AI/AN people, this means that the trauma of the “soul wound,” or what has been conceptualized as the American Indian genocide, may be felt by current generations, contributing to the prevalence of many of the risk factors for suicide, even though these people did not directly experience the historical events. The theory surrounding AI/AN historical grief was initially founded on studies of secondary traumatization among families of Holocaust survivors. Secondary traumatization is used to explain the symptoms associated with knowledge of a traumatic event experienced by a significant other (Jervis et al., 2006). An important focus in the study of historical grief is how the effects are passed down through time. One possible explanation is that the trauma experinced in the initial generation resulted in poor parenting skills which led to an indirect parent to child transmission of the initial trauma (Whitebeck et al., 2004). However, the more common reasoning, especially with relation to AI/AN people, is that the historical trauma becomes a part of the collective community consciousness and subsequently the individual identity. The existence of a historic consciousness among AI/AN people has rarely been studied and deserves further attention especially because it plays an important role in the theory of historic trauma. In 2006, a study of two tribes living on reservations demonstrated, perhaps for the first time, that, at least in these tribes, the people had an awareness of tribal specific historic events and thought that the events influenced their communities (Jervis et al., 2006). In recent years, the idea of historical trauma has become popularized and is the subject of some debate. However, this concept has significance for many AI/AN people and should be considered as an influence on suicide patterns.
For AI/AN people, the concept of historical trauma takes on more significance because the acculturation process that began with the arrival of Europeans continues today while much of the historical trauma remains unresolved and unrecognized. As a result, everyday circumstances, especially on tribal lands, can serve as reminders of the initial trauma and the continued loss of culture. Elders who were interviewed regarding historical trauma listed loss of language, loss of traditional community relationships, and loss of tribal lands as among the results of historical trauma which most concerned them. These losses were associated with feelings of depression and anger (Whitebeck et al., 2004). Though the focus of this study was on the existence of historical trauma, the examples which the AI/AN people discussed were also related to present conditions. Loss of language and loss of community relationships, for example, were results of the separation of families and displacement of tribes following the arrival of the Europeans but these effects are also related to present-day conditions. Therefore, rather than attempting to distinguish between the effects of historical grief and the effects of current loss of culture, these related occurrences may be best seen as the results of the same process which began in the late 1400s and extends through to the present.
Acculturation has been connected to increased rates of alcoholism, family conflict, and adolescent suicide. The extent and expression of acculturation can take several different forms and one of the weaknesses in current studies is a failure to distinguish between different types of acculturation. Acculturation is often understood as the equivalent of assimilation, or the loss of tribal identity resulting from the spread of the dominant culture. However, there is also integration: identifying with both a cultural and a dominant identity, separation: maintaining tribal identity and rejecting the dominant culture, and marginalization: failure to identify with any culture. Several studies have pointed towards a connection between acculturation and suicide. For example, a 22 year study on the New Mexico Apache, Navajo, and Pueblo communities found a correlation between acculturation level and suicide rates; the Pueblo experienced both the highest level of acculturation and the highest suicide rates while the Navajo experienced the lowest level of acculturation and the lowest suicide rates (Leach, 2006). Acculturation is often accompanied by factors such as poverty which influence suicide rates and more research is needed to determine how acculturation interacts with these additional factors.
The loss of identity is one of the most significant results of acculturation in relation to the effect on individuals and an understanding of suicide. The disruption in community identity, represented in the concerns over loss of language and loss of traditional community relationships, results in a corresponding loss of personal identity for individuals living within the community. Among adolescents, the lack of personal continuity between past, present, and future has been correlated with heightened suicide risk. Another study found that the presence or absence of coherence through time in life stories was a distinguishing factor between suicidal and nonsuicidal youth (Alacantara and Gone, 2007). Therefore, in AI/AN tribes which are experiencing high levels of acculturation, the youth may be at risk for suicide because they too are failing to construct a cohesive identity.
Oppression and racism have long been a part of the acculturation experience for many AI/AN tribes and the internalization of oppression has been suggested as a possible mechanism for the relation of acculturation to the prevalence of depression, suicide, alcoholism and abuse among some tribes. The dominant culture within the United States has constructed AI/AN people as “stoic savages” thereby depriving them the right to experience emotion and grieve for their losses. Meanwhile, the dominant culture has also been “whitewashed” of all guilt and as a result, the AI/AN people have nowhere to direct their anger in response to historical trauma and current acculturation. The accumulation of these repressed emotions then results in violence directed towards themselves and their families in the form of abuse, suicide and drug use. The extent to which internalized oppression influences an individual and a community depends upon the extent to which that community has experienced social, economic, and political oppression by the dominant culture (Poupart, 2003).
Protective factors may mitigate the effects of suicide risk factors and therefore, may offer an understanding of suicide patterns among AI/AN people. Adherence to tribal spiritual practices is correlated with decreased suicide attempts and is well established in the literature on AI/AN suicide (Alacantara and Gone, 2007). Among individuals from a Northern Plains tribe living on or near a reservation, high levels of cultural spiritual orientations (based on an index compiled by tribe members and tested for relevance), even when adjusted for age, gender, education level, alcohol and substance abuse and mental distress, were correlated with reduced risk of suicide attempts. The author suggested that cultural spirituality may offer a way to bring meaning and order to an understanding of the world and thereby increase resiliency (Garroutte et al., 2003). If this is so, cultural spirituality may offer a way for youth to build a coherent individual identity which can reduce suicide risk. More studies are needed on tribal variations in the influence of spirituality, as spiritual commitments may also be a source of stress and, furthermore, cultural acceptance of death could potentially increase suicide. In addition to spirituality, strong family connections, communication with family regarding problems, self reported communication skills, social support, positive perceptions of education, a nurse or clinic at schools and positive relationships with tribal leaders have all emerged as protective factors. The influence of protective factors was reinforced in a study which showed that the increase in protective factors significantly decreased suicide risk and was even more influential then the reduction of risk factors. (Alacantara and Gone, 2007).
Though the needs of AI/AN communities are severe there has been a lack of resources devoted to addressing physical and mental health, preventing suicide, and addressing substance abuse. The responsibility for these issues has been placed on The Indian Health Service without a corresponding commitment of resources. The US Commission on Civil Rights in 2003 pointed out the lack of federal financial support of AI/AN health services and labeled the unaddressed health needs of the AI/AN communities as the most severe of any group within the United States. Furthermore, when funds are allocated to states, AI/AN communities often receive a disproportionately small amount of the money. This constant uncertainty of funding can jeopardize current programs and prevent the initiation of new programs. Isolation of reservations and scarcity of professionals willing to work on reservations also impedes the development of successful health programs. Even when health facilities are available, cultural mistrust and inability to afford care can prevent AI/AN people from seeking help (Olson and Wahab, 2006).
Suicide prevention programs usually approach the problem through community and/or individual focused intervention. Individual intervention includes targeting youth through the identification of risk factors and offering help to youth who have expressed suicidal ideation or who have previously attempted suicide (Olson and Wahab, 2006). Few rigorous studies have been completed to determine the efficacy of various suicide intervention programs within AI/AN communities. However, a study in a New Mexico tribe after the implementation of a community-based suicide prevention program found a significant decrease in suicidal behavior and suicide attempts though suicide deaths remained constant during the study. This program approached suicide as stemming, not just from the individual, but from the complex interaction of many psychological, social, and environmental factors (Allacantara and Gone, 2007).
The high suicide rates among American Indian and Alaskan native peoples must be acknowledged and addressed without any further hesitation to allow those who are suffering to heal. However, healing must begin at the root of the problem, where issues such as poverty, poor physical and mental health resources, historical grief and acculturation, and discrimination erode away at the resiliency which has kept cultures and people alive in the face of incredible adversity. The number of factors which influence suicide patterns can appear overwhelming and unapproachable but losing hope is not an option. The interconnectedness of the issues discussed here can seem to reach an unapproachable complexity but this connectedness is, in fact, a great boon and also the foundation for community-based interventions. By building up the resiliency of individuals through the reestablishment of social support networks and revitalization of cultural traditions in combination with providing access to health resources, the entire community can be strengthened.
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