Healing a Wounded Past

Link to MinorityNurse.com

Historical Trauma: A Cascade of Harms

In presentations to nursing school programs in Milwaukee and Kenosha, Wis., American Indian nurse-presenter Lea Warrington, RN, BSN, manager of the Gerald L. Ignace Indian Health Center in Milwaukee (Gemaqua22@ yahoo.com), reviews the traumatic events resulting from U.S. government policy on Native American health in the 19th and 20th centuries. While not intending to represent all Indians, Warrington sets out the facts she has found about the impact of earlier federal legislation on American Indians' health.

Solving the "Indian Problem" by Breaking the Tribal Bond: Federal Policy on Indian Health, 1850-1950 Assimilation was forced through:

Illness/murder (reservations; laws restricting free movement; food withheld or stockpiled and no hunting/fishing allowed; disease with no medical treatment; resistors sent to prison, murdered)

Boarding schools (kidnapping; personal humiliation; renaming and little to no contact with families; abuse; survivor syndrome, failure to fit in, intergenerational family bond breakdown)

Urbanization/relocation (promised jobs, housing and financial support did not materialize; those returning home no longer fit in)

Termination/allotments (61 Indian tribes terminated in late 1950s to early 1960s; large tracts of land signed over without consent of the population; created internal war and conflict; damage from destroying land base of people who saw themselves as part of the land)

Genealogy-Dawes Act of 1887 (identify Indian by blood quantum; can claim only one tribe; those less than 1/4 of any tribe not "Indian"; disruption of Indian identity, family, clan ties)

Defining Historical Trauma

Maria Yellow Horse Brave Heart, MSSW, LCSW, PhD, research professor at the University of Denver Graduate School of Social Work, is the initiator and primary developer of historical trauma theory, intervention models and curricula. She defines historical trauma as "cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma."

Brave Heart introduced historical trauma theory and applications in the late 1980s when she started to see her Lakota Indian community's past as a linked sequence of "unresolved grief." She defined the concept and developed grief resolution interventions to deal with specific phases in the historical trauma and responses to it. Her pioneering research has been disseminated in numerous publications and through workshops and community education she provides through The Takini Network, Inc., in Rapid City, S.D. (takininet@aol.com).

Brave Heart's definition has been adapted by Native nurse researchers Roxanne Struthers and John Lowe in their work on nursing interventions for healing historical trauma in Native Americans.^1-5

The Conceptual Framework of Nursing in Native American Culture

This diagram (shown above), developed as part of the ongoing Nursing in Native American Culture project, shows seven dimensions and their characteristics in Native American nursing practice. The model is pictured as a circle, based on the ancient Native American medicine wheel with four sections divided by a crossbar.

The round shape expresses a circular holistic worldview, with intertwining and overlapping of the constituent qualities, known as the "indigenous oneness" common to many U.S. tribes. The framework was developed from several focus groups held during annual Native American Nurses Summits of the National Alaska Native American Indian Nurses Association (NANAINA) starting in 1997. It has been published in several journals with continuing development and applications up to the present.2, 5

The seven dimensions of the model can guide nursing care to Native American patients who exhibit physical and mental/emotional signs and symptoms resulting from historical trauma. The sensitive questions that Native nurses must ask about past family and community experience will demonstrate respect for Indians' wounded past and will help establish a relationship of trust. This becomes the "healing space" for working together with the patient to recognize and recover from the harms of historical trauma. Native American nurses can offer presence, exchange, unconditionality, respect, trust, partnership and silence.

While the "caring" dimension is thought to be common to both Native American nurses and the mainstream Western nursing discipline, the other six dimensions are distinctive to how Native nurses describe what they do. The connectedness and interdependence qualities are, in fact, in opposition to key Western values such as autonomy, control, competitiveness and plan-oriented time. The focus group members' descriptions, in their own words, can be used to evaluate Native nurses' interactions with Native patients as well as to enhance mainstream nursing knowledge.

Centuries of genocide, cultural destruction and prejudice have left Native Americans an ongoing legacy of serious health problems. Indian nurses can play a crucial role in helping patients begin the process of healing from historical trauma.

By Louise Kaegi

Lea Warrington, RN, BSN, gives a presentation on historical trauma to nursing students at the University of Wisconsin-Milwaukee.

"Just being born American Indian brought me into the legacy of harm and poor health," asserts Roxanne Struthers, RN, PhD, CTN, assistant professor at the University of Minnesota School of Nursing in Minneapolis and president-elect of the National Alaska Native American Indian Nurses Association (NANAINA).

"I have seen in my family the effects of disease-TB and other epidemics with no resistance and little or no treatment. And not only disease [but also cultural loss]. My mother's first language was Ojibwe; she was beaten when she spoke it, then her only language, at a rural reservation school. Later, she would not allow us to speak it at home. Now as a nurse, all the diseases I encounter every day [in Indian patients]-alcoholism, drug dependence, diabetes, overeating-I see as parallel to my own life. Some younger nurses may not be as aware of this at first, but it will resonate when they hear the history."

John Lowe, RN, PhD
"That's when I started to see-and later I started to hear more," recollects Lillian Rice, a Forest County Potawotami Tribe Native practitioner and alcohol/drug counselor, born in backwoods Star Lake, Wis., and now living in Minneapolis. Then only 17 years old (in 1949), she linked the negative behavior of a close family member sinking into alcoholism with what she had heard earlier as a child from her grandmother. The grandmother had told of TB epidemics and children's deaths, of scarlet fever quarantining with confiscation of Native ceremonial paraphernalia, of relocation without treatment or recompense, of going back home and finding the old estate burnt down by the U.S. government. Other family members brought forth painful memories from boarding school days of horsewhipping and humiliation.

"That's when I decided to become a healer," says Rice, who leads women's sweat lodges and women's spiritual gatherings. "After raising my five children and getting into chemical dependency work, I made a decision with a promise to the Great Spirit to be there for [Indian] women in honor of my grandmother."

"If you are Native and born into a Native family, your community's past is a part of who you are," attests John Lowe, RN, PhD, a faculty member at Florida Atlantic University's College of Nursing in Boca Raton and a researcher/designer of Native American teen interventions to prevent and reverse substance abuse and reduce HIV/AIDS risk. "I was raised in a Cherokee farming community in the Southeast and went to school there," he says. "My father, now 80, would have had to go to boarding school, so he didn't go to any school. He was needed on the farm and his parents did not want their kids taken away. [I used to wonder,] why didn't my father have the problems we see so often [in Indian communities], such as alcoholism and diabetes? Why was he OK? When I went away to attend a college nursing program in the 1970s, I took with me that vision of my father. He knew who he was: Cherokee, with traditions, values and beliefs. He faced many barriers, but something within him was very grounded and centered, and that kept him OK. If we [as nurses] could understand it, that is what we should promote."

These Native American health practitioners are describing historical trauma. Although of recent coinage as a term, its devastating effects on the physical and mental health of American Indians and Alaska Natives have been documented for decades. Native healers, with their feeling for root causes, have tapped traditional spiritual resources to help put their families and communities back on a path to recovery. Now, working right in the mainstream of Western health science, leading Indian health professionals and researchers have given the concept a scientific name and a place for testing in their disciplines. The literature is now packed with empirical clinical evidence and qualitative data. Promising new models of care are emerging.

And today at the front lines, strategically positioned to put these models into practice, are Indian nurses. Their recognition of who they are and what they do has inspired a call to action for Native nurses: to recognize the critical role they can play in helping their people begin the process of healing from the harms of historical trauma.

Connecting, Listening, Empowering

How does the healing start? For Native nurses, it begins with knowing yourself, your community and your common past.

"First, heal yourself," urges Struthers. "The healing of one is the healing of all. Then you can share [with patients]. It does ripple out. You can reassure your patients by saying, 'You are not unusual, you are not alone.' History lessons are OK, too."

Rachel Wright, RN, BSN, a master's student in the nurse practitioner program at the University of Oklahoma College of Nursing in Oklahoma City, talks in terms of empowering patients.

Roxanne Struthers, RN, PhD, CTN
"In fact, I think that's the main thing nurses can do," says Wright, whose father is Cherokee. "I agree that I see many Native American patients with social problems associated with physiological problems, but I believe that some of those are related to the self-esteem issue, lack of knowledge and lack of confidence to make lifestyle/behavioral changes that impact their health status. Any patient who feels like a failure and does not understand the problem most likely will not comply with the treatment plan. The nurse or nurse practitioner must help patients learn appropriate knowledge and skills to help themselves."

To get compliance and accurate information from your patients, make sure the communication connection is two way, advises Lea Warrington, RN, BSN, manager of the Gerald L. Ignace Indian Health Center, an urban Indian Health Service facility in Milwaukee. Warrington, who is of Menominee Indian heritage and visits the reservation frequently, often finds out what's really going on with her patients-as opposed to what's in the clinic record-when she encounters them on their own "turf."

Communication failure may come from passivity or not wanting to cause conflict, Warrington warns. Take the case of a 72-year-old patient whose daughter found all his medication bottles unopened in his medicine cabinet. The patient's record at the clinic showed that he had very literally answered "yes" when asked whether he had filled his prescriptions and "no" as to whether he "had any problems with them."

The Conceptual Framework of Nursing
in Native American Culture
Often, after patients leave the facility, Warrington hears complaints about the way the clinic works, or about problems with service, that never showed up on the returned patient satisfaction surveys (usually checked off as "excellent"). "Outside the clinic, even though I work there, patients open up because we are in our own common setting, such as the elderly center, the school or on the street," she explains.

Native nurses who work within the mainstream Western health care system face a paradoxical challenge, Warrington adds. "I believe that Native patients appreciate that Natives work in health care centers," she says. "But I think, though, that sometimes we end up having to prove that we can provide as good service as non-Natives. It's an odd situation to be in, because of the way Native people perceive the overall health care system as not being Native-friendly."

Reducing Suicide Risks

"Start off with questions checking for traditionality and family connectedness," suggests Dan Edwards, DSW, director of the University of Utah School of Social Work and Native American Studies in Salt Lake City. This information is essential for effective assessment, particularly in the mental health area, such as evaluating suicide risk.

Three first questions, suggests Edwards, might be: Where do you live? Do you know the [tribal] language? Have you ever been to your own tribal ceremonies? (For example, a female patient could be asked, "Have you ever been to a kinaalda [a Navajo coming-of-age ceremony for girls]?") Then, he says, "as you establish rapport and if the patient seems open to it, you can begin talking about spirituality and religion."

Edwards is of Yurok heritage, with pre-1970s personal experience with foster care, adoption, boarding schools and assimilation pressures. He has observed the links for bad parenting and high divorce rates, heavy drinking patterns, vulnerability to negative peer pressures and suicide clusters.

Alaska Natives and American Indians rank first among all ethnic groups in suicide rates. While the particulars vary for subgroups-e.g., Indian people living in cities versus rural areas and reservations-the causes can be traced to historical trauma.

"The lost birds-Native Americans who were adopted out or in foster care and have completely lost their culture-are at high risk for suicide and/or risk-taking behavior if they have not successfully taken on their new family's ways to a level of comfort that will offset these problems or if they have not sought their own culture later in life," explains Margaret P. Moss, RN, DSN, assistant professor at the University of Minnesota School of Nursing and a Native Investigator (Hidatsa/Lakota background) in research.

Getting the complete family and lifestyle picture is also critical for suicide prevention in Indian teens and young adults, a particularly high-risk group, adds Faye Annette Gary, RN, EdD, the Medical Mutual of Ohio Professor of Nursing for Vulnerable and At-Risk Populations at Case Western Reserve University's Frances Payne Bolton School of Nursing in Cleveland.

Gary, who gave a presentation on Native adolescent health and preventive education at NANAINA's ninth annual Summit in Park City, Utah, last September, urges Native nurses to recognize the profile: male, between 15 and 24; single; likely to be under the influence of alcohol before suicide attempt; lived with a number of ineffective/inappropriate parental substitutes. Familiar historical trauma issues include "once a resident in boarding schools with frequent moves," "in confinement centers at early age" and "experienced a loss of a significant other through violence."

Healing Through Reconnecting

To get ideas for meeting the toughest health care challenges, such as diabetes, periodically review the Native American nursing literature-especially the articles published by Struthers, Lowe and other Native nurse researchers as part of the ongoing Nursing in Native American Culture project (see "References" and "The Conceptual Framework of Nursing in Native American Culture").

Diabetes, suggests Struthers, can be looked at in a current community context along with a racial memory of the past-the taking of Indians' land, with no more hunting and fishing; forced relocation interfering with diet and exercise; and the poor food choices that come with poverty.

Talking circles-community sharing groups based on Indian tradition-are being tried in many places to help patients deal with diabetes self-management and emotions. In two circles (for diabetes and domestic violence) at the urban clinic where Warrington works, patients learn to listen as well as talk, taking turns with "the talking stick." The groups start by smoking cedar or sage in a shell (sometimes called smudging), which has a calming effect, and then close down the circle the same way.

Lowe offers a scenario, summarized below, showing how the conceptual nursing framework's connectedness dimension might work for an Indian patient with diabetes:

The nurse listens to a patient describe how he has been managing his diabetes. She is seated next to him about one foot away. There may be long periods of silence, but the nurse appears comfortable and does not ask demanding or threatening questions.
Conversation ensues, centered around who the patient's family members are and his everyday life and activities. The nurse talks about the community the patient lives in and resources available.
As the patient talks about the foods he eats, the nurse does not act condescending in her reply about foods he should be avoiding. Instead, she talks about alternatives and options available to the patient. The nurse knows that family and community must be involved and that the patient may need to be encouraged to use them as a resource and to allow them to help him.
The nurse remains nonjudgmental by respecting what the patient shares. He is encouraged to talk and holistically express who he is in his everyday life and activities, his beliefs, his strengths, his management of his diabetes, and who he is connected to, such as family, community and other elements of the creation/universe. There may be storytelling and the nurse may share similar experiences.
Native American nurses sometimes connect at a deep indigenous "oneness" level when caring for another Native American, especially in talking about how the past, present and future have affected them in similar ways.3

And finally, for a tested model of customizing interventions for a specific tribe, review Lowe's ongoing work on Cherokee self-reliance and its application to substance abuse and other nursing interventions for teens.4 On a lifelong quest to understand what kept his own Cherokee father "OK" in the midst of cultural devastation, Lowe has analyzed the historical trauma dealt repeatedly to Cherokee men and the misguided policies and health concepts imposing non-Cherokee notions of independence.

Revealing the true Cherokee conception of self-reliance, which rests on being responsible, being disciplined and being confident, has produced a model that will work for holistic nursing assessment of Cherokee patients. Promotion of the core Cherokee value of interdependence promises to help overcome many of the ills that have come from disconnection and non-Native concepts of self.

Louise Kaegi is a Chicago-based free-lance writer specializing in health care, ethics, education, cultural politics and cultural competency.

References

1. Struthers, R. and Littlejohn, S. (1999). "The Essence of Native American Nursing." Journal of Transcultural Nursing, Vol. 10, No. 2, pp. 131-35.

2. Lowe, J. and Struthers, R. (2001). "A Conceptual Framework of Nursing in Native American Culture." Journal of Nursing Scholarship, Vol. 33, No. 3,
pp. 279-83.

3. Lowe, J. (2002). "Balance and Harmony Through Connectedness: The Intentionality of Native American Nurses." Holistic Nursing Practice, Vol. 16, No. 4, pp. 4-11.

4. Lowe, J. (2002). "Cherokee Self-Reliance." Journal of Transcultural Nursing, Vol. 13, No. 4, pp. 287-95.

5. Struthers, R. and Lowe, J. (2003). "Nursing in the Native American Culture and Historical Trauma." Issues in Mental Health Nursing, Vol. 24, No. 3, pp. 257-72.