Understanding the Link Between Racial Trauma and Substance Use among American Indians

Abstract

Historians and scholars from various disciplines have documented the pervasive influence of racism on American society and culture, including effects on the health and well-being of American Indian (AI) people. Among the many health problems affected by racial discrimination and oppression, both historical and current, are substance use disorders. Epidemiological studies have documented greater drug and alcohol-related morbidity and mortality among AI/ANs compared to other ethnic groups, and culturally appropriate, effective interventions are sorely needed. As part of a larger community based participatory research project to address substance use disparities in rural AI communities, we collected qualitative interview data from 25 AI key informants from a frontier reservation in Montana. Using a semi-structured interview guide, we asked participants to discuss their perceptions of the causes of substance use problems and barriers to recovery on the reservation. Although no questions specifically asked about discrimination, key informants identified stress from racism as an important precipitant of substance use and barrier to recovery. As one participant stated: “Oppression is the overarching umbrella for all sickness with drugs and alcohol.” Participants also identified historical trauma resulting from colonization as a manifestation of race-based stress that drives behavioral health problems. Findings suggest that interventions for AIs with substance use disorders, and possibly other chronic health problems, may be more effective if they address social determinants of health such as racial discrimination and historical trauma.

American Indian/Alaska Native (AI/AN) communities suffer significant health disparities related to substance use disorders (SUDs), including disproportionate prevalence of past-year and lifetime SUD, greater morbidity and mortality rates, and significant unmet need for treatment (Greenfield & Venner, 2012; Chartier & Caetano, 2010). In 2014, 16.1% of AI/ANs met criteria for SUD, compared to 6.8% of all Americans (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Among individuals above age 12, AI/ANs are more likely than any other ethnic group to experience an illicit SUD, and have nearly equal rates of alcohol use disorder (AUD) and other SUDs (SAMHSA, 2016). Between 2007 and 2009, the age-adjusted alcohol-related death rate was 520% greater among AI/ANs compared to the U.S. population, and the mortality rate from illicit drugs was 22.7%, nearly double the rate in the general population (Indian Health Service, 2014). Of all ethnic groups, AI/ANs evidence the highest death rate from illicit drugs (Centers for Disease Control and Prevention, 2011) as well as the greatest need for alcohol treatment (Chartier & Caetano, 2010).

In Montana (MT), 12 different tribal groups comprise 6.6% of the population, with many AI people residing on one of seven reservations in the state (U.S. Census Bureau, 2017). Between 2003 and 2007, the mortality rate associated with illicit drugs was 21% among AIs, compared to 13% for MT overall and 11.6% for the nation Department of Public Health and Human Services; DPHHS, 2017). Disparities in alcohol-related mortality rates were more striking, with 52% of AI deaths in MT attributed to alcohol, compared to 13% in the state overall and 7.2% in the nation (DPHHS, 2017). The past-year binge drinking rate among AI adolescents in MT was 40.7%, compared to 26.6% in the nation (DPHHS, 2017). Related to these disparities, AIs have an average life expectancy 19 years shorter than the state’s White residents (DPHHS, 2015).

In Search of Root Causes

Extensive research has been conducted to understand the etiology of AI/AN health disparities in SUD. For example, rates of well-established SUD risk factors such as poverty, trauma exposure, and post-traumatic stress disorder are significantly higher in AI/AN communities (e.g., Whitesell, Beals, Big Crow, Mitchell, & Novins, 2012), and likely contribute to the elevated substance use and SUD. Different cultural norms and social prescriptions for normative drinking behavior also may play an important role given AI/AN peoples’ recent history of using alcohol as an intoxicant compared to other cultures (e.g., Frank, Moore, & Ames, 2000). Research has implicated cognitive factors, such as stereotyped beliefs about biological vulnerability to alcohol problems (i.e., the “firewater myth;” LaMarr, 2003). Greater levels of belief in this widely-endorsed myth were associated with greater alcohol use and consequences among non-abstinent AI/ANs (Gonzalez & Skewes, 2016), suggesting that culturally specific drinking expectancies and motives warrant attention. Historical trauma also has been linked to substance use among AI/ANs (e.g., Whitesell et al., 2012; Brave Heart, 2003).

Researchers also have attempted to identify biological mechanisms, such as genetic predictors of alcohol metabolism, to explain the high rates of AUD among AI/ANs (e.g., Enoch & Albaugh, 2017). Biological risk factors for SUD are important to consider and indeed may vary between groups. For example, genetic variations that predict low levels of aldehyde dehydrogenase 2 (ALDH2), an enzyme responsible for breaking down alcohol in the body, have been found in 36% of people of Asian descent (Brooks, Enoch, Goldman, Li, & Yokoyama, 2009). Low ALDH2 causes the alcohol flushing response and nausea in response to alcohol consumption, and low rates of alcohol dependence have been found among people with this genetic variant (Brooks et al., 2009). Despite extensive research conducted in search of a genetic explanation for high rates of AUD among AI/ANs, little evidence has been found in support of the biological vulnerability hypothesis (Enoch & Albaugh, 2017). Although genetic factors do clearly play a role in the risk of developing AUD across racial groups, biological factors have not been shown to account for greater risk among AI/ANs compared to other populations (e.g., Ehlers & Gizer, 2013). Current empirical evidence suggests that efforts to ameliorate AI/AN disparities in SUD might yield better outcomes by targeting psychological and environmental risk and protective factors amenable to intervention. Toward the goal of identifying key risk and protective factors to intervene upon, we asked community members from a rural AI/AN reservation to share their perspectives on the causes of SUD and pathways to recovery in this initial phase of a larger intervention development project. Through in-depth semi-structured interviews, participants emphasized the pervasive influence of historical trauma and current racial trauma as powerful risk factors for SUD and barriers to recovery. Interestingly, there is no evidence of SUDs among AI/ANs prior to contact with European settlers (Hawkins & Blume, 2002), suggesting a link between SUD and the devastating effects of colonization. Next, we provide a brief review of the history of AI/ANs in the U.S. to provide context for the findings on racial trauma.

Racial Trauma Among AI/ANs

Historical Sources of Trauma

From the inception of the nation, the founders of the U.S. had difficulties in their relationships with the Indigenous peoples. After the Columbian exchange of diseases decimated the original inhabitants of the nation (Thornton, 2000), systematic efforts were made to exterminate or subdue survivors and accommodate expanded European colonization (Dunbar-Ortiz, 2014; Waziyatawin, 2008). The Spanish used AIs as slaves until the casualties of disease forced a need to seek slaves from Africa (Dunbar-Ortiz, 2014; Nies, 1996). Other European immigrants sought resources for personal gain and land for farming, bringing their desires in direct conflict with the residents who had preceded them.

European colonists held to an understanding of manifest destiny that they believed gave them a divine right to the land and its possessions (Deloria, 2003; Dunbar-Ortiz, 2014; Echo-Hawk, 2013; Nies, 1996). Inherent within that understanding was a belief in White supremacy—the notion that European culture was superior to Indigenous cultures. Manifest destiny and the desire for expansion contributed to federal policies devised to remove lands that were, in the colonists’ eyes, used by the Indigenous peoples in inferior ways, and to eradicate these inferior people and cultures. These racist beliefs, rooted in beliefs about European superiority, remain powerful influences today.

Policies that followed from these colonial belief systems and worldviews have been detrimental to the physical, psychological, and spiritual well-being of AI/ANs. Colonial expansion resulted in approximately 100 years of wars with numerous tribes, despite their concessions (Brown, 1972; Dunbar-Ortiz, 2014; Nies, 1996). Treaties were made only to be broken when colonists desired further expansion. A number of federal policies were enacted to deliberately destroy Indigenous ways of life, cultural practices, traditional languages, spiritual beliefs, ceremonies, and family systems (Spring, 1994). Many of these policies persisted into the modern era and have had lasting impact.

Racist Policies in the U.S

Once defeated on the battlefield, AIs/ANs were subjected to policies meant to strip away their identities (Deloria, 2003; Dunbar-Ortiz, 2014; Echo-Hawk, 2013; Waziyatawin, 2008). Children were forcibly removed from their families and shipped away to Indian Residential Schools, sometimes hundreds of miles from the reservations. The stated goal of the residential school movement was forced assimilation—to “Kill the Indian, save the man,” (Zalcman, 2016). At the schools, children were forbidden to speak Native languages or engage in their traditional cultural and spiritual practices, and were punished severely when they did. Often children did not see their families and communities for years at a time; many were abused and many died at the schools (Adams, 1995), often without any report made to their relatives. Communities and families, in turn, endured unspeakable trauma from the loss of their children. The residential school movement lasted until the 1970s and created generations of people traumatized by the destruction and demonization of their culture, disconnection from families and communities, and cruel tactics of assimilation. Many AI/AN elders alive today will share stories about their boarding school experiences.

Other racist policies persisted well into the 20^th Century. It was not until 1948 that all AI/AN people gained the right to vote—28 years after the 19^th amendment gave women the vote (Dunbar-Ortiz, 2014; Nies, 1996). Native women endured forced and undisclosed sterilization sponsored by the U.S. government until the 1970s (Lawrence, 2000). Efforts were made by the federal government in the 1950s to early 1960s to terminate what few rights had been allotted to tribes with the goal of disbanding treaty-recognized sovereignty and to confiscate reservation lands (Dunbar-Ortiz, 2014; Nies, 1996). Religious freedom for AI/ANs was not protected until the American Indian Religious Freedom Act was passed in 1978 (Pevar, 2012). Another racially motivated law passed by Congress in 1832 prohibited the sale of alcohol to AI/ANs until 1953, when Congress gave tribes control over alcohol policies in their communities (Kovas, McFarland, Landen, Lopez, & May, 2008). The law arose from stereotyped beliefs that AI/ANs were biologically inferior to European Americans and unable to manage alcohol consumption (Hawkins & Blume, 2002; LaMarr, 2003), perpetuating the “drunken Indian” myth that has had lasting impact on AI/AN identity and current tribal alcohol policies.

Present Day Racial Trauma

Racism and racial trauma continue to impact AI/ANs. For example, they are victims of violent crime more often than any other racial group—more than twice as often as other U.S. citizens (U.S. Department of Justice, 2004). In 2015, AI/ANs accounted for 3% of all hate crime victims, much higher than would be expected given their representation of 1% in the population (Federal Bureau of Investigation, 2016). They also are more likely to be arrested, convicted, and receive more severe sentences compared to the general population, and therefore are overrepresented in prisons (U.S. Sentencing Commission, 2013). In MT, although AI/ANs constitute just 6.6% of the population, they represent 33.4% of federal offenders (United States Sentencing Commission, 2013). Moreover, they are more likely than any other group to be killed by police, with rates of law enforcement killings of 6.6 people per million AI/AN men aged 25–34, 5.9 aged 35–44, and 4.6 aged 20–24, compared with 1.2 per million people in the U.S. as a whole (Center on Juvenile and Criminal Justice, 2014). These disparities reflect deep-seated beliefs about AI/ANs and can be considered both causes and effects of racial trauma.

Microaggressions and Everyday Racism

Acts of prejudice and discrimination toward AI/ANs occur on a daily basis. One study examined the experience of racial microaggressions among AI/AN adolescents and found that 98% of the sample reported experiencing some form of discrimination every day (Jones & Galliher, 2015). Perceived discrimination has been significantly associated with hopelessness (Jaramillo, Mello, & Worrell, 2015) and consistently associated with poorer alcohol outcomes among AI/AN youth (Whitbeck, Chen, Hoyt, & Adams, 2004; Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001). In a large study with AI/AN adults, discrimination was reported on a near-daily basis, with the experience of race-based superiority being most common. In that study, discrimination was significantly associated with psychological stressors such as increased anger and personal distress (Gonzalez et al., 2016).

Traumatization and Re-traumatization

The racial traumas discussed above have contributed to the health disparities prevalent in Indian Country today, including disparities in AUD/SUD and co-occurring problems like depression, suicide, and violence (Brave Heart, 2003; Moghaddam, Momper, & Fong, 2013; Warne & Lajimodiere, 2015). In addition, AI/AN people are often re-traumatized due to vulnerability resulting from their substance use (e.g., Mandavia, Robinson, Bradley, Ressler, & Powers, 2016), as well as by continued racially-rooted oppression. One salient example of recent events that risked re-traumatization of AI/AN people has been the callous disregard by business entities in constructing pipelines through treaty lands, re-enacting many of the abuses experienced in the past (APA, 2017). The Dakota Access Pipeline originally was intended to cross the Missouri River just north of Bismarck, ND, but was rerouted due to concerns by the U.S. Army Corps of Engineers about potential negative environmental effects in that (predominantly White) area (Dalrymple, August 18, 2016). The differences in assessment of risk for the Bismarck citizens versus the AI/ANs living on the nearby reservations may be difficult to reconcile until one considers the history of race-based prejudice and discrimination discussed previously.

Addressing Racial Trauma in Treatment

Despite its link to SUD, addressing racial trauma has not adequately been considered when developing or adapting empirically supported interventions (Blume, 2016; Myhra & Wieling, 2014; Warne & Lajimodiere, 2015). Research shows that racial microaggressions are positively associated with alcohol use and problems (Blume, Lovato, Thyken, & Denny, 2012) and perceptions of racial bias have been reported in SUD treatment that may interfere with the working alliance (Davis & Ancis, 2012). Strangely, racism as a potential stressor related to substance use or as a potential threat to recovery from SUD seems to be rarely discussed by treatment professionals (Burris, 2012), and unwelcoming racial climates in treatment may be linked to poor treatment outcomes (Blume, 2016).

Present Study—the Substance Abuse and Resilience Project

The Substance Abuse and Resilience Project is a collaboration between researchers from a research-intensive public university, a reservation tribal college, and reservation community members. Tribal partners are located on a geographically isolated reservation spanning approximately 2.1 million acres. The reservation is home to approximately 12,000 enrolled members of two tribal nations that were historical enemies. Racial trauma in this region began in earnest when colonists desired the gold in the Black Hills, sacred lands secured by Indigenous people in previous treaties. War began when the U.S. allowed prospectors to despoil the sacred area, and became especially brutal after the defeat of General George Custer (Nies, 1996). The federal government implemented a policy to wipe out the bison as a means of destroying the peoples of the Northern Plains (Smits, 1994). The U.S. army pursued the people, resulting in atrocities such as the massacre at Wounded Knee. Here, as in other areas of North America, cultural and religious practices were banned and children forcibly removed from their communities to attend boarding schools (Waziyatawin, 2008). A variety of adverse social and health consequences occurred as a result of this systematic mistreatment. Currently, the study site is located in one of the 100 poorest counties in the U.S. (Norris, Vines, & Hoeffel, 2012) and morbidity and mortality data qualify the reservation as one of the least healthy areas in the nation (MATCH Project, 2015).

The Substance Abuse and Resilience Project is grounded in a Community Based Participatory Research (CBPR) framework, a partnership approach to research that equitably involves the community in all aspects of the research process, builds upon existing strengths, and aims to bring direct and sustainable benefits to the community (e.g., Wallerstein & Duran, 2010). This framework is considered best practice for research with AI/ANs (Burhansstipanov, Christopher, & Schumacher, 2005; Christopher, Watts, McCormick, & Young, 2008), and our community partners expect this approach for all research on the reservation. The overarching goal of the project is to develop a culturally grounded, community driven intervention to address SUD disparities and foster resilience. This manuscript reports qualitative findings from a key informant interview study, which served as the first step of this multi-year, mixed methods intervention development project. We focus on thematic content related to racism, oppression, historical trauma, and lack of positive cultural identity as perceived causes of SUD and barriers to recovery. We then discuss implications for public policy and treatment.

Method

This qualitative interview study was conducted in Fall 2015–Spring 2016 with a purposive sample of tribal members residing on the reservation (N = 25). All study materials and procedures were reviewed and approved by the CAB, tribal institutional review board (IRB), and university IRB. Interviews were conducted by members of the research team over two separate occasions approximately 1–2 months apart. They lasted 1–2 hours for each segment, for a total of 2–4 hours per participant.

Recruitment

Recruitment took place via nomination by the community partners and personal invitation by the local project manager, a well-known and respected tribal member with extensive community ties. Through a series of meetings, the research team and CAB discussed and assembled a list of community members knowledgeable about substance use, tribal culture, and reservation life. From this list of potential key informants, the project manager selected participants with varying characteristics to capture the diversity of the community, including men and women from both reservation tribes, and from different reservation towns, age groups, spiritual beliefs, and with varied personal histories with SUD. Of those invited, only a few declined, citing mostly scheduling difficulties and logistical barriers.

Participants

Participants were enrolled tribal members, 13 men and 12 women, aged 28–79 years (M = 51.68, SD = 14.54). Interviews were conducted over two sessions, with 24 completing both (96% retention rate). One participant answered nearly all the questions during the first session and elected to withdraw before the second session due to scheduling conflicts.

Participants reported high educational attainment and income relative to the reservation as a whole, with 79.2% having completed high school and 37.5% having graduated from college with an associate’s degree or greater. Annual household income ranged from $0–$60,000 (M = $27,910, SD = $19,980), with 55% reporting ≤ $30,000, and household size ranged from 1–15 people (M = 5.24, SD = 4.54). Another study surveyed 288 tribal members at the same reservation and found that 47% reported annual household income of $2,500 or less and 76% reported $10,000 or less (Brockie, Dana-Sacco, Wallen, Wilcox, & Campbell, 2015). Thus, participants tended to have greater socioeconomic status than the overall population, which likely influenced their responses. Although this purposive sample was not randomly selected, it was appropriate for the initial hypothesis-generating phase of the project.

Interview Protocol

The interview protocol was carefully developed with input from AI scholars and addiction researchers, community members, consultants, and the tribal IRB. Eleven iterations of the interview guide were needed to ensure that the information gathered was comprehensive and the questions phrased in a culturally appropriate, unbiased way. The domains represented in the final protocol included: 1) cultural conceptualizations of health and sickness; 2) reservation life; 3) substance use and problems; 4) getting through addiction problems; 5) help-seeking; 6) setting goals for change and harm reduction; 7) recovery barriers and facilitators; and 8) maintenance of behavior change and relapse prevention. We included questions about local language and preferred terminology to describe relevant constructs, as well as process questions about participating in the interview study. Although no questions specifically asked about racial trauma, themes related to colonialism and oppression, historical trauma, discrimination, and ethnic identity strongly emerged from the data.

Interviewers and Interviewer Training

Four members of the research team served as the interviewers, including two European American academic researchers (one male, one female) and two AI community researchers (both female). The community researchers were the project manager and a respected elder from a different reservation in the state. Each session was conducted by a team of one academic and one community researcher, as it was deemed important to have an AI person present during the discussions. The primary interview questions were asked by the academic researchers, with the community researchers following up the main questions with probes to facilitate the discussion. The community researchers also facilitated the informed consent process, debriefing, and helped to establish rapport with participants. Process questions showed that participants felt comfortable with and enjoyed the interview process.

Prior to data collection, the researchers engaged in training and discussion about best practices in interviewing from the perspective of psychological science and from the perspective of AI communities. The project leader’s mentor, an AI clinical psychologist and SUD researcher, traveled to the reservation and facilitated the training, which included a pilot test of the interview protocol with community members followed by feedback. The AI community researchers also provided advice about cultural differences in communication style, such as slower speech, less frequent direct eye contact, the importance of allowing silence during conversations, and when/how to interject with probes. They gave feedback and suggestions to the academic researchers during the pilot interviews and throughout the study. As an example of the guidance they provided, the AI members of the team encouraged the “outsiders” to spend a few minutes at the onset of the interviews to share some personal information— for example, about one’s cultural heritage and family—to connect with participants and find common ground. This guidance was incredibly helpful, as evidenced by the participants’ stated comfort with the interview process and the depth and sensitivity of the information that was gathered.

Procedure

As part of the CBPR process, the authors spent significant time building relationships with community members, visiting with stakeholders, and participating in community events for more than one year prior to data collection. After homing in on a set of research questions that were deemed priorities for the community, we continued the CBPR process by hiring a local project manager and assembling a Community Advisory Board (CAB), consisting of tribal members who serve as co-researchers. The CAB was an integral part of the research team, and provided advice and feedback about all stages of the research. The CAB reviewed the project materials and we collaboratively revised the study questions and methods in light of their input. The reservation has its own independent IRB that approved the overall project as well as the methods used in this particular phase of the research.

Interviews took place in a private room at the tribal college library, and refreshments were served. Following an in-depth discussion about the study and provision of informed consent, participants completed a brief demographic questionnaire and gave consent for the conversation to be audiotaped using sensitive digital recorders. At the end of the first data collection session, key informants were compensated with a $25 gift card and a tentative date was set for the second session. After the second session, they received a $50 gift card and were informed about the team’s planned dissemination efforts.

Data Management and Analysis

Recordings were transcribed verbatim by a professional transcriber, then checked for accuracy and de-identified prior to analysis. Qualitative data were managed using the Atlas.ti qualitative analytic software package (version 7.1.0; Friese, 2013) and analyzed using team-based open coding and content analysis in accordance with the techniques of grounded theory, an inductive approach that allows the theory to emerge from the data (Corbin & Strauss, 2008). Transcripts were examined line-by-line, with coders assigning open codes to categorize data and identify emergent themes. Related codes were identified and linked according to broader analytic categories, or focused axial codes (Charmaz, 2014). We then examined the thematic content in relation to the participants’ demographic characteristics, examining codes between and across transcripts. Finally, we presented the themes to our community partners, and together we discussed and debated how to interpret them. While CAB members did not have access to transcripts due to confidentiality concerns, they did participate in interpreting the findings by reviewing written summaries of the findings, examining de-identified illustrative quotations, and discussing cultural meanings underlying thematic content. In accordance with the principles of CBPR and the tribes’ preferences, we disseminated the findings to participants and other community members via an interactive community forum. Next, we report themes that emerged from the data with a special focus on those related to racial trauma and healing.

Findings

Participants emphasized their understanding of substance use and other harmful health behaviors as resulting from other community-wide problems that must be considered within the broader social, cultural, economic, political, and historical context in which individual behaviors occur. In fact, when sitting down to interview the key informants, many prefaced their statements by saying, “Before I answer your questions, you need to understand what has happened to our people in the past.” A number of interviews were preceded by lengthy discussions about the history of the region and its peoples, often taking place as part of the informed consent process.

All participants acknowledged that SUD is a grave and growing concern for the reservation and its residents. In particular, key informants expressed concerns with methamphetamine use, which has ravished the region in recent years. Methamphetamine use was perceived to be of epidemic proportions and was attributed in part to the oil boom that began in the area 10–15 years ago. Alcohol use also was a prevalent concern, followed by nonmedical use of prescription drugs. Participants linked substance use with other community problems, including poverty, homelessness, domestic violence, and child abuse. However, they also emphasized that these interrelated community concerns are symptoms of larger problems—namely, a history of colonialism and racism—that have affected the community for generations. As one participant explained, “Oppression is the overarching umbrella for all of sickness with drugs and alcohol.” (P08)

SUD as a Symptom of Poor Community and Socioeconomic Health

Nearly all participants (22 of 25) viewed SUD as a problem affecting the entire community and as a symptom of poor community health. Poor community health, in turn, was explicitly linked to economic hardship. For example, one key informant stated:

“Economically, we’re very isolated, and there’s very few economic opportunities here or, like, jobs or businesses or stuff like that. So that’s the challenge of just staying and surviving. Having a job, being able to pay the bills, stuff like that. I think other communities probably have the same problem. That’s one of our main challenges here at [reservation], just being able to survive. Just putting food on the table and paying for things.” (P03)

Another key informant similarly identified economic hardship as a threat to community health and risk for SUD. This participant discussed poverty in tandem with intergenerational trauma, saying:

“People can’t understand…there’s intergenerational trauma, and then this need to belong, with such a high rate of poverty, a high rate of unemployment—they say it’s like 80% on the reservation.” (P13)

The extent to which participants linked economic hardship to substance use was evident in various key informant quotations. For example, participants understood alcohol and drug use as a way to cope with poverty and its associated challenges:

“They spend their time getting high, and when they get high it’s like nothing else probably matters to them. They forget their problems they’re having…I always think the kids in these poor communities, they’re having no hope: ‘Well, I’m not going to be able to get a house. I’m not going to be able to get a car or find a job. But I can find a joint. I can find a pill or something like that.’” (P03)

“My mom said when [the factories] started closing down and laying off people, that’s when she noticed more drinking, the kids being less taken care of…she noticed that’s when those jobs started disappearing and nothing to replace them. That’s when she noticed more alcohol and drug abuse increasing.” (P04)

Along these lines, many participants recommended economic solutions to the social and health problems in their communities, including SUD. As is evident in the quote from Participant 13 above, however, participants also perceived the risk from socioeconomic conditions on the reservation to be inseparable from other community-wide risk factors such as intergenerational and historical trauma.

History of Colonization and Poor Community Health

Key informants discussed how historical factors—colonialism and forced assimilation in particular—resulted in the dire socioeconomic conditions and poor community health associated with current problems with SUD. The majority of participants (15 of 25) described how a history of violent colonialism and forced assimilation created systems of inequality and cycles of abuse that have impacted the health of reservation residents from one generation to the next. In particular, racism and White supremacy were seen as motivating cultural assimilation through boarding schools and other unjust mechanisms of cultural eradication. This forced assimilation resulted in a key precipitating factor in SUD—loss of Native culture and traditions. When asked what causes SUD, one participant stated:

“That separation in the community. One is supremacy, slave master, power. The other community is dependent, poor, and inferior. So there’s the communities. To go back to family now, talking about the tribal side is that they experienced all the racism, discrimination, and unequal [treatment]…and it appears in anger, violence, and alcohol.” (P11)

Similarly, other participants explained:

“On a larger scale, we display symptoms of postcolonialism, so postcolonial stress disorders are symptomatic in our society here. It’s intergenerational. Due to the fact that we’re survivors of the American Indian holocaust, we have a genetic predisposition as survivors to what they’ve termed postcolonial stress disorder…so there’s microaggressors in society that trigger these posttraumatic stresses.” (P13)

“We can go back to historical trauma, to our ancestors being shoved here on the reservations and boarding schools, whatever that may be. And then that trickling down to my mother [who] would hit me because her mother hit her because her grandmother hit her. And we don’t even know that real reason…that’s a way the traumatic event still affects what you’re dealing with.” (P09)

Key informants perceived these forms of racial trauma, grounded in beliefs about the fundamental inferiority of AI people, to be root causes of present day substance use and SUD.

Historical Trauma as a Consequence of Colonization and Cause of SUD

Participants viewed trauma, grief, and repeated losses as important causes of SUD and barriers to recovery. Furthermore, they named historical trauma as a culturally specific challenge for AI people. Themes related to historical trauma and colonization emerged from 15 of the 25 interviews. The following quotes illustrate the perceived burden of historical trauma on the reservation:

“We carry hurt from 4, 5 generations ago, when the Census first came out and they started shipping them to Carlisle and all that stuff, you know? It’s still there, and people don’t want to talk about it because it hurts.” (P08)

“I really believe in the historical TRAUMA. I really believe that. I just…that feeling of helplessness. I know what my grandmother went through when she was dragged off to boarding school. I just think that permeated down. It still does.” (P04)

One key informant discussed an epigenetic explanation for historical and intergenerational trauma:

“There’s a hole in your heart that cannot be filled due to losing a loved one, due to something that happened maybe 3 or 4 generations ago with our grandparents. We carry that, but we don’t know what it is. And if we don’t know what it is, and we’re not offering things to help our children and our people understand, then how are we going to heal? So you have intergenerational trauma. You carry that, and it’s in our genetics.” (P08)

Participants clearly identified historical trauma, rooted in the racist worldviews and practices of colonialism, as a causal factor driving poor community health and SUDs.

Modern Racism, Microaggressions, and Institutional Racism

In addition to historical trauma and racism, eight of the 25 key informants also described the individual and collective consequences of everyday racism and discrimination. Eight participants noted that the historical trauma of colonization of their Native communities is repeated and relived in the present day through modern forms of everyday racism and microaggressions. The stress of racial discrimination was seen to motivate drinking or using drugs to cope, resulting in problems for the community. For example, one key informant stated:

“[With microaggressions] you’re just reminded…subconsciously you’re just remembering that some great injustice has occurred in the past to your people and that every day you have to fight this…you’re on an uphill battle from this. So on some level you just start your day off knowing that it’s going to be a challenge trying to accomplish things that you need to accomplish just to survive on a survival level…then you have microaggressions that undermine your ability to function.” (P13)

While discussing barriers to recovery, the same participant described the existence of AI mascots as a modern-day form of racism:

“There’s microaggressors, you see them in, like, mascots, you know, with the Redskins and the Chiefs and all these things with the tomahawk chop.” (P13)

Furthermore, participants described seeing common relics at reservation businesses that serve as reminders of past segregation laws and policies. For example, a key informant described the following stressful experience as a trigger for alcohol use:

“You’re going down the street and you see a sign that says, ‘No Indians or dogs allowed.’” (P11)

The participant stated that racial segregation persists in the reservation communities and discussed the effects of institutionalized racism, saying:

“The community has two factions. There’s a White community and the Indian community. The communities do not know each other.” (P11)

Health care and education in particular were perceived as perpetuating inequality through institutionalized racism:

“Because you literally have a clinic for non-Native Americans and a clinic for Native Americans. The better clinic is the non-Native.” (P04)

“School stops and bang, you’re thrown out of the White community. You’re not allowed to be part of that. You don’t count no more. You’re not bringing anything to the schools. Money, I’m talking about. So anyway, it just ends right there. Right after graduation. You’re an Indian. You’re not allowed…It’s institutionalized racism, and even in that, people, non-Native people will categorize you. Even in an outside institution…like college, whatever. The difference in communication styles, the difference in humor…I mean all of those little differences and nuances. If you don’t realize that there is a difference, you begin to think, ‘What’s wrong with me?’ And every Native person that goes to the service gets named ‘Chief.’ Is your name Chief? …Again there’s that barrier. Same with the school, public school. But anyway, you’re trying to be what’s being taught. You’re trying to be part of that, and you’re not allowed. You’re not recognized. And you develop an anger because there’s something wrong. Same with the public school systems. You’re doing all the things, and someone calls you a dirty Indian, and you’re in a fight. Well, the fight, then there’s punishment. But the one who started [it] never gets punished. It’s only the Indian community that gets punished.” (P11)

Experiences of racial discrimination were discussed in depth throughout the interviews, and racial trauma was perceived to be closely linked to SUD disparities affecting AI people.

Racial Trauma and Loss of Identity

Participants described loss of cultural identity as the mediating link between racial trauma and SUD—that is, they identified loss of AI culture and identity as the primary mechanism by which historical racism produced and modern racism perpetuates the social and health problems facing the reservation. Of the 25 key informants, 10 linked loss of individual identity to substance use, 15 identified lack of cultural identity as a risk factor for SUD, and 11 identified having a strong sense of Native identity as a protective factor. The key informants perceived substance use to be an attempt to fulfill an unmet need for belonging, for identity, for cultural and spiritual connection. In fact, participants described substance use as a way to form a new (albeit unhealthy) identity and sense of belonging when traditional pathways to positive cultural identity have been blocked by historical trauma and racism. One key informant explained the powerful influence of identity conflicts on substance use:

“Nobody knows what the hell their roles are in our society. There’s nobody there to guide you through the pathway of the things you need to do to be able to participate in the first ceremony. There’s no one there to help guide them in finding their way to who they are. Today there are so many definitions of what an American Indian is…Where are you going to fit? What do you have access to that gives you an identity and a soul? So instead of becoming a well-rounded American Indian within your tribe, a well-rounded tribal member where you fit healthily and you’re in balance, we now have classifications…traditionalist, super-traditionalists…Indians who can’t quite fit into the other categories but are at the edge, so they start to drink a little bit every day. Drug a little bit every day. So what I think is wrong is we are in an identity crisis, and we are also in a crisis of determining standards that are acceptable, and they’re not clearly articulable nor are they defined nor are they embraced by the community.” (P02)

Others articulated the need for culture and spirituality as crucial for identity and healing:

“Culture plays a critical component of helping a person have an identity … spirituality and culture are integral to that identity. What has replaced culture and spirituality has been the drugs, the meth, the alcoholism, and everything else. And the people who participate in that have created their own society. They have created their own spirituality.” (P02)

“Because I think a big problem with why our people can’t recover is because they have no identity. Without culture, without spirituality, where is the identity? …But getting back to that addiction part, one of the biggest factors into that is they have loss of identity. And why I came back and why I’m sober is because I had identity. I had something to come back to.” (P05)

Congruently, one of the primary recommendations for addressing SUD on the reservation was to reclaim positive cultural identity:

“And then the other thing is their identity. What place do we have in this world? Where were we born? And you help them, you know—‘you’re very important. You’re very significant.’ And you develop that nurture, and all of a sudden that makes it an awakening for some people. And then their value becomes real to them, and then that changes their substance abuse.” (P09)

Discussion

Key informant interviews in this initial phase of an ongoing intervention development project yielded rich data from which a number of themes related to racial trauma and healing emerged. Overall, participants viewed substance use and SUD as symptomatic of underlying trauma and poor community health. Poor community health was linked to historical trauma resulting from colonization and from recent racial trauma in the form of microaggressions and institutionalized racism. Racial trauma was seen as affecting health outcomes by eroding a positive sense of self and cultural identity, and proposed solutions included grounding prevention and treatment programs in Native culture and spirituality.

These findings demonstrate that AI/AN people are cognizant that historical forces and racial oppression continue to affect their communities. Considering the number and severity of racial traumas perpetuated against Indigenous people, including deliberate attempts by the U.S. government to exterminate them and eradicate their cultures, it is impossible to ignore the powerful resilience that counteracts the traumas AI/ANs have endured. Participants identified as survivors and credited their survival to the strength of their cultural beliefs and practices, suggesting that healing from racial trauma begins with the culture and is grounded in AI/AN traditions, beliefs, and ways of life. With regard to SUD in particular, AI/AN people have long declared, “Our culture is our treatment,” (Gone & Calf Looking, 2011, p. 293). Culture as treatment should not be confused with culturally tailored or culturally sensitive interventions. Indeed, revitalization of AI/AN culture in and of itself has been proposed as a promising method of healing a variety of health problems and social ills, including SUD, posttraumatic stress, and historical trauma (e.g., Gone, 2009). Treatment in the form of sweat lodge ceremonies and cultural immersion camps appeals to AI/AN clients (e.g., Gone & Calf Looking, 2015), although they have not yet been tested as stand-alone treatments using rigorous study designs. Still, they remain promising avenues for healing racial trauma and associated health consequences.

Clearly, racial trauma must be addressed in prevention and treatment efforts aimed at decreasing SUD and improving health among AI/ANs. As stated previously, psychological interventions frequently fail to consider racial trauma and healing in the course of treatment. AI/AN people who are struggling to change their substance use behavior may benefit from efforts to understand the various sources of trauma that have led to their current distress, including individual, intergenerational, historical, and racial trauma. Once identified, the compounded effects of these personal and collective traumas must be addressed. One approach is to change how people respond to or cope with trauma. If maladaptive behaviors and SUDs are symptoms of underlying distress, then teaching clients new ways to manage symptoms may be helpful. However, individual coping skills are only one part of the equation. A real solution will necessitate changing the broader socioecological systems underlying the problem. Most importantly, we must stop retraumatizing AI/AN people through unust policies, continued treaty violations, disrespect of cultural heritage, and ongoing microaggressions and everyday discrimination.

Healing the racial traumas that contribute to AI/AN health disparities will require individual, family, community, socioeconomic, and systems-based approaches. Adequately funding the Indian Health Service (IHS) is a reasonable starting point. The IHS is the primary source of health care, including psychological treatment and behavioral health services, for many AI/ANs, and is severely underfunded (Sarche & Spicer, 2009). Not only does IHS need funding for psychological services, it also needs quality providers who are knowledgeable about ways to address symptoms of racial and historical trauma. Research is sorely needed to understand best practices for addressing racial trauma in clinical practice, and on effective ways to train practitioners to deliver interventions. Cultural competence and cultural humility remain widespread needs for those working in Indian Country.

Addressing the symptoms of historical and racial trauma also requires socioeconomic justice through development on AI/AN reservations. Key protective factors identified by participants in this study included having a job, an education, and opportunities for personal growth and fulfillment. Research shows that employment predicts positive treatment outcomes (e.g., Walton & Hall, 2016), and this may be true for AIs as well (Dickerson et al., 2011). When the bison were removed from the Great Plains and relocated to Yellowstone National Park in the late 1800s (Smits, 1994), the people’s primary source of food, shelter, clothing, tools, and work was eliminated. This deliberate effort to eradicate AI/ANs had profound effects still felt today. Despite recent efforts to restore bison herds to reservations, job training and employment opportunities are few. As participants attributed community problems to lack of identity, opportunities to facilitate identity development through meaningful work are needed.

Policy changes also are needed to address the racial traumatic victimization, revictimization, and social oppression linked to AI/AN substance use and other health problems. Policies are needed that respect tribal sovereignty and acknowledge real threats to AI/AN culture that have been imposed by past legislation. For example, before the Indian Child Welfare Act was passed in 1978, as many as 25–35% of all AI/AN children were in foster care with non-Native families (Jones, 1995). Foster parents lacked knowledge about tribal culture and way of life, and therefore many AI/AN children were raised without knowledge of their cultural identities. Recently, policies such as Indian Education for All, a program that requires AI/AN history to be taught in MT’s public schools, have been implemented to improve historical knowledge about the original inhabitants of the land. Teaching Native languages in schools is another promising means of promoting a sense of cultural identity for AI/ANs—and, we argue, may benefit the entire population. Increasing knowledge of AI/AN history and culture among White people may counteract stereotypes linked to microaggressions, another source of trauma identified in this study.

Addressing microaggressions will require efforts aimed at improving coping skills among AI/ANs in tandem with efforts aimed at non-Native populations to decrease the incidence of everyday racism. It is tempting to examine racial trauma as a characteristic of the individual who suffers from it, especially when that individual is engaging in harmful behaviors like using substances. While instilling emotion regulation and other coping skills surely is worthwhile, this cannot solve the problem on its own. A comprehensive, multi-layered approach is needed to build individual skills, family cohesion, and community resilience, while simultaneously targeting the perpetrators of racial trauma. As microaggressions are rooted in implicit bias (Sue et al., 2007), educational campaigns to educate non-Native people and communities about implicit bias and stereotypes about AI/ANs may be useful. Widespread cultural change is needed to raise awareness about the harmful effects of microaggressions on people of color (and research is needed to identify effective interventions for reducing microaggressive behavior) so that discrimination toward AI/ANs is reduced.

Limitations and Conclusion

The present research generated promising hypotheses regarding the role of racial trauma in substance use and SUD among AI people residing in rural reservation communities. However, there are some inherent limitations of the study design and research methods that must be considered. First, we could not test hypotheses using the qualitative methods of this study, and findings should be considered tentative until appropriate hypothesis testing can be performed. Findings are not intended to generalize beyond the present sample, which is not representative of the population as a whole. Although we used purposive sampling to recruit key informants with diverse demographic characteristics, the present non-random sample was more educated and of higher SES than the reservation population. We interviewed key informants who were motivated to share their perspectives on substance use and SUD recovery, which by necessity excluded a number of voices that remain unheard. Future research is needed to test the hypotheses generated in this research with a larger, more representative sample, using quantitative methods. Moreover, the decision to have the interviews conducted by the non-Native academic researchers in the presence of an AI community member may have influenced responses in ways about which we can only speculate. Still, these findings offer important insights from the perspective of AI community members that contribute to the psychology literature on racial trauma and healing.

In sum, this study provided evidence supporting the role of racial trauma in poor community health and SUD among AI/ANs. Comprehensive SUD prevention and treatment programs that incorporate strategies to address racial trauma are needed. These programs should consider ways to improve coping skills and nurture resilience among AI/AN clients while acknowledging the current and historical contexts in which health disparities emerged. In particular, there is an urgent need for economic development on reservations and policies that respect tribal sovereignty and cultures. Moreover, efforts are needed to change stereotypes and implicit biases about AI/ANs in order to reduce microaggressions and other forms of discrimination. Above all, social movements that increase social, economic, and health equity are needed to halt the cycle of victimization and revictimization perpetuated against AI/ANs since the early days of colonization.

Biographies