Wicasa Was'aka: Restoring the Traditional Strength of American Indian Boys and Men

Abstract

We examined health disparities among American Indian men and boys within the framework of historical trauma, which incorporates the historical context of collective massive group trauma across generations. We reviewed the impact of collective traumatic experiences among Lakota men, who have faced cross-generational challenges to enacting traditional tribal roles.

We describe historical trauma–informed interventions used with two tribal groups: Lakota men and Southwestern American Indian boys. These two interventions represent novel approaches to addressing historical trauma and the health disparities that American Indians face.

We offer public health implications and recommendations for strategies to use in the planning and implementation of policy, research, and program development with American Indian boys and men.

ALTHOUGH AMERICAN INDIANS make up the smallest US ethnic group, they have ranked highest among ethnic and racial groups in health disparities.¹ Addressing the lack of consensus on a definition of health disparities,^2,3 Braveman defined them as

potentially avoidable differences in health (or in health risks that policy can influence) between groups of people who are more or less advantaged socially; these differences systematically place socially disadvantaged groups at further disadvantage on health.^3(p180)

According to the Indian Health Service, American Indians in the 12 Indian Health Service areas have higher rates of death from tuberculosis (500% higher), alcohol (514%), diabetes (177%), unintentional injuries (140%), homicide (92%), and suicide (82%) than all other US ethnic and racial groups.⁴ These health disparities among adult populations have extended to youths as well.^5,6 Using the Youth Risk Behavior Surveillance Survey to examine disparities between American Indian youths and other racial and ethnic groups, Pavkov et al.⁶ found that American Indian youths had higher rates of suicidal ideation and attempts, substance use, and smoking than did youths of other racial and ethnic groups. In addition to these health disparities, a recent nationwide study⁷ found that urban American Indians living in Indian Health Service areas were approximately twice as likely as the general population in these areas to be poor, unemployed, and without a college degree. Similar disparities have been found among American Indians living in rural reservation communities.⁸

Death rates of male American Indians have exceeded those for their female counterparts for every age group up to age 75 years and for six of the eight leading causes of death.⁹ These disparities in men's health disorders (i.e., cardiovascular disease, cancer, diabetes) have been compounded by high rates of suicide,^9,10 substance use,^11,12 and psychiatric disorders, which have had a disproportionate impact on American Indian boys and men. Although research examining the health of American Indian boys and men is scarce,^9,13,14 researchers have found that five of the top 10 leading causes of death have been related to voluntary risky behaviors that might be preventable with appropriate public health interventions.¹³ From 2001 to 2005, 11.7% of all American Indian deaths were attributed to alcohol, more than twice the rate of the general US population.¹¹ Accidents, suicide, and homicide have reached epidemic levels among American Indian boys and men,⁹ and their rates of violent victimization were higher than those of all other races.¹⁵ The prevalence of lifetime posttraumatic stress disorder among two large reservation-based American Indian samples exceeded that of Whites in the general US population.¹⁶ Primm et al.¹⁷ called attention to the role of public health in addressing disparities among racial and ethnic minorities in mental health disorder prevalence rates, access to care, and sources of care, and proposed that interventions address social determinants as well as outcomes.

We examined health disparities among American Indian men and boys within the framework of historical trauma, which addresses historical context and collective massive group trauma among this population. We considered the impact of American Indian men and boys’ collective traumatic experiences and used the framework of historical trauma to inform interventions aimed at ameliorating the suffering of American Indian men and boys and improving their behavioral and overall health. We posited that incorporating conceptualizations of traditional American Indian male roles in tribal cultures, and the impairment of those roles to varying degrees across generations, would assist in understanding the complex challenges American Indian men and boys continue to face.

Restoring American Indian men to strength again—to be wicasa was'aka (“strong men” in Lakota) and to once more be the warriors and protectors of Native nations—may facilitate improved health for American Indian communities.

CONCEPTUAL FRAMEWORK OF HISTORICAL TRAUMA

The historical trauma paradigm frames life-span idiosyncratic trauma in a collective, historical context, which empowers American Indian survivors of both communal and individual trauma by reducing their sense of stigma and isolation. The historical trauma response refers to the theoretical concept of a constellation of features that have been observed among massively traumatized populations, including depressive symptoms, psychic numbing, self-destructive behavior, and identification with the dead, among whom vitality in life is seen as a betrayal of ancestors who suffered so much.^18,19 Individual trauma responses have been viewed as emerging from genocide, oppression, and racism. This response diminishes the shame and self-blame that survivors often experience. Historical unresolved grief, a component of historical trauma response, is akin to prolonged or complicated grief²⁰ but includes the generational collective experience of unresolved grief.

Historical unresolved grief incorporates prolonged bereavement over cross-generational collective losses that underpins recent deaths; ancestral losses are often mourned as though they are recent, as manifested in oral testimonies of the experience of such grief as persistent. Many American Indian communities have faced frequent, multiple traumatic deaths as a result of elevated morbidity and mortality rates, lower life expectancy, and high rates of accidental death.²¹ However, most grief research has focused on conjugal bereavement rather than the extensive premature and traumatic losses experienced by American Indian communities. Traditional mourning practices and cultural protective factors were impaired by the federal prohibition against the practice of traditional ceremonies from around 1883 until the 1978 American Indian Religious Freedom Act; some practices related to traditional burials are still not permitted. Extensive close kinship networks, common among American Indians, may result in frequently experiencing the deaths of close attachment figures; intense positive attachment to the deceased may be a risk factor for complicated or prolonged grief. American Indians’ quality and intensity of interpersonal attachment may differ from that of the dominant cultural society. For example, a tradition in some tribal groups is to cut one's hair when a close relative dies, which is a manifestation of the degree of attachment and the sense of a loss of part of oneself. To effectively address grief and loss, interventions must incorporate an understanding of traditional normative grief resolution as well as the magnitude of traumatic deaths that American Indians continue to face, as evidenced by the high mortality rates.^4,9,11,21

HISTORICAL TRAUMA'S IMPACT ON TRADITIONAL LAKOTA MALE ROLES

The impact of historical trauma upon American Indian males includes the challenge of defining their roles and position in modern society. In order to appropriately intervene with American Indian boys and men, it is helpful to consider how the collective traumatic history of tribal communities has contributed to the erosion of traditional male roles, as illustrated here among the Lakota.

Wicasa Was'aka, the Traditional Protectors

Among the Lakota (Teton Sioux), a Northern Plains tribal culture, men were the protectors of the nation, the wicasa was'aka (strong men). Wicasa was'aka were exemplified by the akicita, members of warrior societies, who were responsible for protecting the tribe, providing for those who could not support themselves, and keeping order in the camp.^22–24 Men developed their skills as warriors to defend the society. The ideal warrior was devoted to ensuring the good of the nation through generosity, self-sacrifice, humility, respect, compassion, hunting skills, and when at home, assisting with caretaking of children.^25–27

Gender roles were complementary; oral testimonies speak of both men and women braiding each other's hair and taking care of the children. Women and children were esteemed as sacred beings, never as men's property. Domestic violence and child abuse were not tolerated; any perpetrator's actions would be avenged by male relatives and often lead to banishment. Having multiple wives did not traditionally involve a sexual union; rather, it involved taking in a wife's widowed sisters to provide for them until they were remarried. Men were esteemed in the tribe on the basis of their generosity (e.g., how much they could give to others, how much they could provide) rather than of their accumulated wealth. War was seen as a last resort because all life was considered sacred. Touching the enemy, or counting coup, was the ideal, not taking the enemy's life. Black Elk²⁷ said that warriors painted their faces black to hide from the Creator because they knew war was not a good thing. After a war, the men would go through purification before reentering the tribal society.

The Lakota warrior was wise, tried to avoid war, and used diplomacy but, when necessary, would defend the society and protect the land. Tatanka Iyotake (Sitting Bull), the consummate warrior and the embodiment of traditional Lakota culture, protected women and children, was respectful of women, and was generous and self-sacrificing for the good of the nation. He dedicated his life to protecting the Lakota and their traditional way of life. Tatanka Iyotake demonstrated woksape (wisdom) in averting a war, courageously going in front of enemy lines, unarmed, to smoke a canupa (pipe) to pray for peace and then inviting others to join him. Both sides were in awe of his behavior and courage and acquiesced to his words advising all to return to their homes.

The colonization of the Americas changed the nature of warfare and the balance of power between tribal groups. The introduction of scalping by Europeans altered the traditional practice of cutting off a warrior's braids, and the introduction of guns and alcohol altered warfare and traditional values.

Impact of Historical Trauma on Lakota Men and Boys

I think losing the land was the most traumatic… . I remember my aunts and uncles and my dad talked about … how they were treated, some were shot… . They were starved… . So this happened in my great grandparents’ generation when they lost the buffalo. My grandparents’ generation lost the land and their livelihood… . That's from generation to generation. There are a lot of answers that I don't have and a lot of questions that I do have and there is a lot of hurt inside me… . Some of these things happening over the years are still happening today, like my grandparents, my great grandparents had their children moved to schools… . I was moved, my brothers and sisters moved… . There's a big hole in my heart. We see it happening to our grandchildren already… . Where does it stop?^28(p256)

The collective American Indian history has been described as genocide.^29–31 The Wounded Knee Massacre in 1890 of Lakota women, children, and primarily unarmed men by the Seventh US Cavalry and their subsequent burial, while some were still alive, in a mass grave followed other collective adverse experiences. The Lakota had already survived war trauma and prisoner-of-war experiences, abject poverty, starvation, loss of the buffalo, massive death tolls, and the imposition of the reservation system. The spiritual and emotional impact of the decimation of the buffalo, viewed as ancestors of the Lakota, was devastating. Land loss was related not only to the alteration of traditional lifeways but also to the Lakotas’ relationship to the land and their sacred responsibility to protect it. Land was the mother, with her own spirit, not something one could own or possess, not something devoid of life. The Wounded Knee Massacre was a deep psychic wound³² to Lakota men because they were unable to perform their traditional sacred roles as the protectors of women and children and the guardians of the land and the natural world.

The Lakota, along with other American Indian populations, suffered another major collective blow with the forced separation of children as young as five from families and tribal communities through compulsory boarding school placement in environments that were often physically and sexually abusive.^33,34 American Indian scholars^34–36 have regarded abusive boarding school experiences as factors contributing to the high rates of domestic violence and child maltreatment that exist in many tribal communities.^37,38

Perpetration of violence against American Indian women by their male counterparts runs counter to the traditional Lakota male role as protectors of the sacredness of women and children. The collective traumatic history of the Lakota and other American Indian populations has reverberated across generations and, we have asserted, has been manifested in more recent morbidity and mortality rates as well as those dating back to the inception of the reservation system.^{4,7,18,19,36,39–44}

A result of this collective experience is male separation from the traditional self, internalization of oppression, and identification with the aggressor—an intrinsically devalued true self. Being a warrior has become, in many instances, associated with bravado and violence rather than with humility, compassion, respect, and wisdom. Whereas once American Indian boys had a role and a place of honor in various traditional societies, today they may gravitate toward gang culture.^24,45 The erosion of fathering among Lakota men,²⁴ in part the result of the destructive influences of boarding schools that undermined traditional parenting roles,^36,39 has contributed to confusion among boys and a lack of clarity regarding the meaning of becoming wicasa was'aka. Structural factors such as on- and off-reservation travel, poverty, substance abuse, family dysfunction, clustered housing, and waning tribal connections have contributed to a process of marginalization, resulting in a vulnerable population of high-risk American Indian boys and an increasing gang presence and gang activity in tribal communities.^2,24,45,46

The experiences of modern-day akicita, those serving in the military and as tribal police officers, have been confounded by historical trauma. The struggle to translate the traditional akicita identity into modern times may be complicated by cross-generational histories of trauma, oppression, and discrimination. Combat exposure is superimposed on intergenerational trauma, as illustrated by this Lakota male veteran with a history of suicidal ideation and parental boarding school trauma and abuse:

I went there [Vietnam] prepared to die, looking to die, so being in combat, war, and shooting guns and being shot at was not traumatic to me. That was my purpose and my reason for being there. What was traumatic for me was that it brought on a lot of rage when seeing other people, the same color as me, being abused by the war. That was the hardest thing while I was there… . I was having a battle with the army I was in.^28(p.259)

Lakota tribal police who volunteered at Ground Zero immediately after the terrorist attacks on September 11, 2001, some of whom were Gulf War veterans, have articulated a traditional identity as akicita. They described cognizance of historical trauma, ongoing trauma exposure, symptoms of posttraumatic stress disorder, and challenges not only at Ground Zero but as first responders on the reservation.^22,23 These modern akicita, who expressed commitment to protect and serve not only the Lakota but all of humanity, are role models for Lakota boys who struggle to navigate the influence of historical trauma and modern cultural conflicts in becoming wicasa was'aka who can serve and protect their communities.

Both Northern Plains and Southwest tribal groups have had greater degrees of trauma exposure than the general population.³⁸ Trauma exposure is an important consideration in these tribal groups’ higher rates of posttraumatic stress disorder and of other health disparities that may be affected by posttraumatic stress disorder.^16,38,47 We have incorporated lifetime trauma exposure and posttraumatic stress disorder symptoms into the historical trauma paradigm. Two culturally appropriate and community-based interventions in two cultural areas, the Northern Plains and the Southwest, have demonstrated creative and unique approaches to addressing the historical trauma that frames the health disparities facing American Indians.^4,7,48

HISTORICAL TRAUMA–INFORMED INTERVENTIONS

The Historical Trauma and Unresolved Grief Intervention is a short-term, culturally congruent intervention for grief resolution and trauma mastery that has been used among a coping segment of an underserved American Indian adult population with elevated health disparities.^18,19 Originating in the Northern Plains among the Lakota, the Historical Trauma and Unresolved Grief Intervention has been delivered to other tribes across the United States and Canada.¹⁹ However, most of the evaluation has been conducted among the Lakota. Short-term outcome measures of the intervention (selected as a Tribal Best Practice in 2009 by First Nations Behavioral Health Association and the Substance Abuse and Mental Health Services Administration) found that, among the sample, Lakota men experienced a greater degree of boarding school trauma, including assault by staff for speaking Lakota and sexual abuse, than did women.⁴⁹ Lakota men had less conscious emotional experience of historical trauma yet reported the occurrence of more traumatic events in boarding schools.

Guilt over the Wounded Knee Massacre was one potential explanation for these differences. Brave Heart⁴⁹ posited that men's historical inability to enact their traditional roles as wicasa was'aka during the Wounded Knee Massacre may have heightened their initial defensive denial of shame and guilt and lessened their conscious awareness of Lakota historical trauma and its impact. Male participants may have used avoidance to defend against their emotional pain. After intervention, men reported increased affect (emotion) tolerance and more joy and decreased psychic numbing as well as greater consciousness of trauma response features. The intervention was held in the Black Hills, a sacred healing place for the Lakota, and incorporated a traditional mourning resolution ceremony (i.e., the Wiping of the Tears) at its end. After the Wiping of the Tears, participants spontaneously testified as to how powerful the intervention was for them, particularly its location in the Black Hills and facilitation of the intervention by Lakota survivors of historical trauma. Follow-up evaluation revealed that both Lakota men and women perceived the Historical Trauma and Unresolved Grief Intervention to be helpful in reducing grief and trauma responses. Participants specifically identified the group processing, the traditional and spiritual components, and the opportunity to work through boarding school trauma as particularly helpful.

American Indian Youth Development

RezRIDERS is a multilevel extreme-sport experiential education intervention that aims to reduce substance abuse and depression and encourage prosocial relationships and positive youth development among high-risk American Indian youths. In addressing historical trauma, participants exercise the transfer of traditional values from adult cultural mentors to youth participants. Cultural mentorship can help youths negotiate contradictions between Western and traditional ways. This negotiation begins during discussions of topics including past, present, and future gender roles and role expectations. The intervention also includes optimism exercises and trust building as peer teams generate community projects, which work to link individuals with their community responsibilities ecologically. RezRIDERS promotes cultural protective factors in challenging environments through use of extreme sport, effectively shifting high-risk behaviors to controlled program settings. This intervention is culturally tailored, using a community-based participatory research approach to meet the needs of each unique tribal setting.

The cultural adaptation of RezRIDERS to each tribal community includes building local tribal research capacities and ensuring that individuals, peers, and the community benefit from research activities conducted in an ecological framework. Designed with an understanding that tribal communities are connected socially, RezRIDERS seeks to spread health promotion and prevention messages within existing high-risk peer clusters using attraction to risk to promote intervention effectiveness and efficacy.⁵⁰ This intervention simultaneously focuses on prevention, reducing substance abuse and depression among American Indian youths, and cultivating community research capacity.

Addressing Historical Trauma Intervention Research

American Indian scholars, clinicians, and prevention specialists^{8,18,34,36,40,41,44,51,52} have increasingly advocated for interventions that incorporate American Indian customs and traditional healing approaches as well as a consideration of historical trauma. Creative and unique intervention approaches, such as the Historical Trauma and Unresolved Grief Intervention and RezRIDERS, cultivate an environment in which it is safe for men and boys to speak about topics that may otherwise not be discussed, such as American Indian men's traditional gender roles. The importance of understanding the traditional cultural context and the impact of the collective traumatic history can inform revitalization of a set of protective factors for American Indian men and boys in other tribal populations. Gone and Alcántara⁵³ reviewed the state of current evidence-based treatments in relation to American Indians; none specifically addressed the historical trauma response. Historical trauma, and interventions designed to improve public health by addressing underlying historical trauma, resonate strongly in many Native communities throughout the United States and Canada.^{8,18,34,36,40,41,44,51,52} Therefore, it is important that the research community continue to build on the existing evidence base, including acknowledging and addressing the challenges endemic to conducting high-quality research in American Indian communities^51,54 while also taking the next step to conduct more scientifically rigorous testing of existing interventions as well as evaluation of potential adaptations based on gender and tribal affiliation.

PUBLIC HEALTH IMPLICATIONS AND POLICY RECOMMENDATIONS

[Healing] means to talk about the past and the future… . That's why we are doing this, it's addressing the issues, I suppose, and that's why the person must come out of the healing, our mourning, our pain.^28(p261)

Considering the complex interaction between the social determinants of health and the sociohistorical context of communities is essential in the development of public health initiatives. For contemporary American Indian men and boys, this context is complicated and includes generations of historical trauma, multiple traumatic losses, changing gender roles, military experience, erosion of traditional male identity development opportunities, and lack of access to health and behavioral health services. Given this context, how can the public health framework best support American Indian men and boys? First, it is imperative that American Indian men and boys be better engaged and have a voice in all stages of policy, research, and program development processes. Second, the continued reality of disparities among this population makes it clear that more knowledge about the experience of American Indian men and boys and their health-seeking processes is necessary, and policy changes need to be made. Third, behavioral health prevention, identification, and intervention should be integrated into service planning and research development to improve health outcomes and address disparities among American Indian men and boys.

We suggest the following strategies for use in the planning and implementation of policy, research, and program development involving American Indian men and boys:

• Create feasible opportunities for American Indian–led research and program initiatives by supporting contemporary American Indian providers and researchers as well as workforce development in both clinical and research professions. This includes increasing access to formalized training through scholarships, fellowships, and other types of support.

• Institutionalize cultural competency training—to include historical trauma, multiple traumatic losses, and issues related specifically to American Indian men and boys—for multidisciplinary health and mental health providers, educators, community gatekeepers, policymakers, law enforcement personnel, and judicial professionals.

• Support research models that engage and empower American Indian men and boys and their communities, such as community-based participatory research, an approach to research that shares ownership between researchers and community, fosters colearning and collaboration, and requires the incorporation of indigenous knowledge into research processes. Community-based participatory research also builds capacity for researchers and community members alike; community members can learn to conduct research activities including grant writing and evaluation (facilitating focus groups), and researchers learn how to host community meetings and learn about community systems, culture, and practices. Support of research models that are based on the community's resources and needs and use both resiliency and disparity frameworks is particularly important for American Indian communities because of the damage caused by stigmatizing research in the past. It is important to build on existing strengths to offer hope and opportunities for community empowerment.

• Support research to establish the impact and utility of the historical trauma treatment models and implementation of such models.

• Support initiatives that look specifically at gender- and age-related issues and at identity development of American Indian men and boys in contemporary and historical contexts.

• Establish practical plans for prevention, early identification, and treatment efforts that are appropriate for American Indian men and boys.

• Support efforts to increase access to affordable health services (including behavioral health) for American Indian populations, including development of telehealth networks and systems for cooperation among service providers to increase availability of care.

• Foster development of places in which traditional healing models are respected and discussed in culturally appropriate ways that honor the traditional role of boys and men across multiple generations; examples could be having a private and protected room designated for traditional healing or holding group sessions for men and boys that allow members to engage in dialogues about traditional male roles in contemporary society.

• Work with communities to establish a framework for discussing traditional healing in the context of research, provision of behavioral health services, or both.

Culturally appropriate, historically cognizant public health models that integrate behavioral and physical health can be used to eliminate the health disparities faced by American Indian men and boys today. As ambitious as this goal may seem, it can be achieved through sustained multilevel support of efforts that empower indigenous voices and knowledge, bring awareness of the impact of historical trauma, and call attention to health disparities and the role that stigma plays in reducing access to services. Through such sustained efforts, researchers and practitioners can support American Indian men and boys to become the resilient and sacred men they were meant to be—wicasa was'aka.