Running head: MENTAL HEALTH AND NATIVE AMERICAN POPULATIONS
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Depression and Suicide: An Underrepresented and Interconnected Mental Health Concern amid
Native American Populations
Susan Brady
University of Colorado Colorado Springs
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Depression and Suicide: An Underrepresented and Interconnected Mental Health Concern amid
Native American Populations:
“The truth is hard to understand . . . unless, unless . . . you have been yourself to the edge of the
Deep Canyon and have come back unharmed.”
—a Tewa Indian elder speaking in the 1940s (Laski, 1959)
Quantifying the frequency and occurrence of depression and other mental health concerns
among Native American Communities often presents a great difficulty. The primary obstacles
are that the diagnostic categorizations given carry excessive stigmatization in Native American
populations and that the vast preponderance of cases is not counted accurately (Cohen, 2008).
People are magnificently complex and complicated. When a label of depression (i.e. a
psychiatric condition characterized by such symptoms as an unhappy mood; loss of interests;
energy, and appetite; and difficulty concentrating) is employed it indicates the existence of
homogeneity in the human experience and a standardization of behavior and symptoms. Simply
put, this just isn’t the case (Watson & Breedlove, 2012). Cohen (2008) argues that this
inconsistency phenomenon is maintained cross-culturally; depression, sadness, melancholy,
grief, heartache, even pain carries distinctive connotations (i.e. meanings, associations, etc.) in
other cultures and languages. In Native American languages and dialects, it is reasonable and
even rational to state that the lexes of sadness, depression and loneliness are expressive and
adjustable rather than analytical and inflexible (Cohen, 2008). Authur Kleinman (1985), a
medical anthropologist, cautions that the use of category fallacy (i.e. the assumption that
categories in one language carry the same meaning in another) furthers the persistent distrust of
western or Indigenous researchers and research being performed. Kleinman (1985) argues that
not only are the psychological words (e.g. depression, sadness, etc.) elucidated differently in
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Indigenous societies; they are even comprised and established as distinct “forms of social
reality.” This is an especially imperative matter when you consider that most psychological,
sociological, etc. studies do not truly consider the diversity of the cultures they are examining
(Cohen, 2008). They seem to have limited knowledge or understanding about what some of these
matters (e.g. depression, abuse, suicide, and mental illness) constitute in these respective
societies and cultures (Cohen, 2008).
Depression in Native American communities is reported to be at least as common as in
Caucasian populations (Cohen, 2008). In general, Native Americans compared with non-Native
Americans are already 28% more likely to commit suicide and in some groups, the number is 10
times higher than the general population (Cohen, 2008). These alarming numbers do not even
include suicide attempts. When evaluating other minority populations with Native American
communities, the Native American population has an elevated frequency of health risk factors,
including suicide (CDC, 2003). These suicidal risk factors include, but are not limited to
addiction, mental disorders, recent severe stressful life events, substance abuse, intergenerational
mental, emotional, physical and sexual abuse (Middlebrook et al., 2001; Hill (as cited by
Vilschick, 2002). There is also evidence that cultural disruption (i.e. socio-historical uprooting
from native lands, forcible attendance of boarding schools, loss of native language, and
associated weakening of parental and community influence) may perhaps be a significant
influencing factor for the elevated rates of suicide amidst Native American communities
(Echohawk, 1997; Range et al., 1999). There is a distinct need to assess, recognize and
understand suicide from a socio-cultural point of view so that we can identify “culturally specific
suicide pathways or trajectories” (Cutcliffe, 2005). This devastating and overwhelming evidence
does not just imply that suicide attempts amid Native American communities are taking place,
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but reveals a substantial psychological suffering (Hill, 2009). It is the twenty-first century and we
are still excluding and marginalizing Indigenous communities (e.g. Native Americans) from
main stream society (Smith, 2012); this happens within the academy as well, along with what
researchers choose or choose not to study--this includes the academy of psychology.
In these conservative times the role of an Indigenous researcher and indeed of other
researchers who are committed to producing research knowledge, who document social injustice,
who recover subjugated knowledge, who help to create spaces for the voices of the silenced to be
expressed and ‘listened to,’ and who challenge racism, colonialism, and oppression is a
precarious responsibility (Smith, 2012). The expectation with this methodical and thematic
collation of psycho-sociological based research is that some new data and evidence will be
brought into the light. This literature review will primarily address two areas within the realm of
psycho-sociological study and within Native American communities--depression and suicide.
Depression:
Cohen (2008) argues that mental illness is not a uniquely individual crisis; it is also a
manifestation of collective bonds and associations, one’s natural (i.e. physical) environment and
the socio-political and fiscal structure in which one resides. Additionally, Hill (2009) argues that
the experiences of Native Americans on the questions of stress, (i.e. an imbalance between
perceived demands and a person’s appraisal of their ability to cope with the demands) depression
and suicidal thoughts are rooted in “historical and contextual elements […such as…] historical
trauma, colonialization, and the loss of connectedness and cultural practices” (Lazarus, 1993;
Hill, 2009). Furthermore, detrimental socio-demographic considerations including economic
hardship, violent behavior, and socio-cultural suffering (i.e. “forced relocation and acculturation,
societal prejudice, and systematic genocide”) suggest that Native American populations are at
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elevated risk for mental illness and inveterate stress (Rieckmann et al., 2004). Extreme social
change (past or recent) damages community integration and kinship and amplifies the risk for
depression as well as suicide (Durkheim as cited in Middlebrook et al., 2001).
Native American and Euro-American communities are both subject to environmental and
biochemical depression. However, there are numerous factors involved in the etiology (i.e. the
study of the causes of diseases) of depression that are each more predominant or exclusive to
Indigenous communities (See Table 1 below) (Cohen, 2008).
Table 1: Etiology of Depression in Native American and First Nations’ Communities
Consequences of reservation and urban lifestyle
Alcoholism
Poverty
Battering, rape, child abuse
Racism and prejudice from Anglo society and internalized as self-hatred
History of abuse perpetrated within residential schools and the church
Grief from loss of family members to suicide, violence, or disease
Grief from loss of lifestyle, language, and culture
Grief from tragic history of one’s tribe and ancestors
Loneliness, including separation from family, tribe, land, and nature
PTSD (Post-Traumatic Stress Disorder) from any of the above, sometimes spanning generations
PTSD from military service and lack of traditional preparation for or healing from the terrors of war
Traditional causes
Initiatory illness, “the wounded healer”
Lack of meaning and purpose
Breach of taboo
Soul loss
Witchcraft/sorcery
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While various illnesses, both physical and psychological, are associated with the above
etiological traditional causes, it would probably not be broadly acknowledged or recognized
amid today’s Native American populations (e.g. depression vs. soul loss). Cohen (2008) stated
that the expression “soul loss” should not be a revelation to those concerned with the treatment
or personal experience of depression; “the depressed person appears hollow, without the spark
and joy of life.” Even without the knowledge of a particular taboo, a breach could be the source
of the depression (Cohen, 2008). However, Cohen (2008) contends that a “lack of meaning and
purpose is pandemic today and may be the psychological root of many cases of depression.”
From an Indigenous perspective, each life has a purpose, significance and a mission (Cohen,
2008). When a life is unbalanced and inconstant, an individual may experience any number of
afflictions. For example, in the Navajo community, a person may experience depression because
he or she is suffering from a spiritual imbalance (Rieckmann et al., 2004). This potentially
imbalanced volatility can be initiated by neglect to themselves or relationships and can produce
anxiety, mood disturbances and depression (Rieckmann et al., 2004).
When considering the wide range of treatments for depression there is an obvious
differentiation in Western and Indigenous/Native American methods (See Table 2 below).
Table 2. Differences between Western and Native American Mental Health Workers
Western Methods
Native American/Indigenous
Focus on disease and diagnostic categories
Focus on health and positive words
Therapist practices a profession learned through books,
Counseling ability may be an inborn gift, may be
academic study, and internship
conferred through initiation and ceremony, developed in
dreams and visions, or learned by observing or
apprenticing to noted healers
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Hierarchical view: therapist is an expert and
Egalitarian view: all people have challenges; transference
authority; transference is common
is uncommon
Oversight by licensing boards
Oversight by community
Interventions generally have a serious tone
Humor is common
Healing accomplished through insight, interpretation,
Healing accomplished through insight, interpretation,
and/or medication
plant medicine, prayer, ceremony, and transpersonal help
from spiritual powers; therapist may acquire new skills or
power to help a particular patient
Therapy practiced in an office
Therapy practiced in nature or in a sanctified space
Treatment may be prolonged, continuing for years
One to four sessions, generally on successive days
Advertising, marketing, and networking are keys to
Therapist has no shingle, advertising and marketing
success
may be considered unethical; Patient finds therapist by
word-of-mouth and by being in the right place at the
right time
Fixed fee for services
No fees, flexible fees, or donation are common; selfless
generosity of healer and patient promotes successful
outcome
Sessions have fixed length
Sessions have no fixed length; may last minutes or
hours
Therapist never touches the patient
Massage, laying on of hands, or other physical gestures
may be part of the treatment
Focus on coping with, managing, or curing mental
Focus on returning to a state of confidence, balance,
disease
beauty, well-being, and harmonious family and
community relations
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As exhibited in the above table, there are critical differences between the Indigenous
methodologies and most of the Western methodologies in approaches to therapy and healing
(Cohen, 2008). According to Cohen (2003), a customary Native American therapy and
counseling option for depression often involves consulting with a sagacious and perceptive elder;
the session may or may not include the individual’s spouse or family members. The session
could employ various methods of focus: inspiring and constructive words, affirmative imagery,
the elder may advise cognitive adjustments in the patient’s mind or may attempt to concentrate
on encouraging and hopeful images in his or her own mind to “exert an invisible, transpersonal
influence on the patient” (Cohen, 2008; Cohen, 2003). These methods are not what one would
typically find in the Western psychology academy, but there are researchers and academics that
pursue these ways of doing, thinking, knowing and being. Smith (2012) stated there are
researchers that determinedly and resolutely choose to investigate the marginalized members of
society; these researchers may come from the very communities that have been cast to the
margins of the social order. Sometimes referred to as ‘insider’ research, there is a section of the
academy that is concerned with studying the marginalized communities and exposing
microcosms of the bigger picture or as paradigms of the societal and cultural pediment (Smith,
2012). This research is necessary if aid is to be found in reducing depression in Native American
communities.
Suicide:
There is a distinct socio-historical perspective that influences and contributes the link
between connectedness, a sense of belonging and the instances of suicide in Native American
populations, but this matter is yet to explored to its proper depths (Strickland, Walsh, & Cooper,
2006; Hill, 2009). Hill (2009) contends that a sense of belonging is a complicated and intricate
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issue that reflects the interconnected psychological, sociological, physical, and spiritual bonds
and unions of individuals, families, and communities. There is a profound transcendent
relationship between family, community, nature, the Creator, land, environment, ancestors, and
the time-honored customs of life and existence. This deep-rooted relationship is an elemental and
central purpose of the Native American community and culture (Struthers et al., 2003 as cited in
Hill, 2009). The core risk factors for attempted suicide in adults are depression, alcohol abuse,
substance abuse and separation or divorce (National Institute of Mental Health [NIMH], 2004 as
cited in Hill, 2009). Frisch and Frisch (2002) characterized suicide as “purposefully taking one's
own life” and suicidal ideation as “thoughts of taking one's life”. Alcantara and Gone (2007)
contend that by and large, the proportion of suicide ideation and attempts to suicide completion
is devastatingly excessive, with a far greater number of cases of suicide ideation and attempts
transpiring in comparison to completed suicides. According to Hill (2009), individuals who
complete a suicidal act are three times more likely to be men than women.
Completers plan the suicide act, whereas suicide attempters tend to act
impulsively. Highly lethal methods are more likely to be used by completers compared
with suicide attempters. Completers generally select a setting which is isolated to limit
disruption, compared with attempters who may notify family and friends and act out their
suicide plan in the presence of others (Hill, 2009).
However, women are more likely to report a history of attempted suicide, at a ratio of 3:1
(NIMH, 2004 as cited in Hill, 2009). Suicide is a critical public health concern in the United
States with current statistics demonstrating that it is the tenth leading cause of death in American
society (CDC, 2010).
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In view of the substantial individual and collective toll of death by suicide, the twentyfirst century has observed a substantial increase in nationwide awareness directed with regard to
the prevention of suicide (Alcantara & Gone, 2007). Alcantara and Gone (2007) argue that
suicide is identified and understood not only as a point of trepidation and worry for individuals
and their relations, but also of the community as a whole; this is in conjunction with the
cumulative urgency and much needed prioritization of suicide studies, investigations and
prevention programs. It is ironic that any ‘‘treatment’’ for suicide must most certainly occur
before the actual event of suicide and a postmortem facilitation of intervention is unmistakably
impractical and not possible, because suicide prevention cannot be rendered for the dead
(Alcantara & Gone, 2007). Because of this Alcantara and Gone, (2007) argue that it is
elementary then to discover reliable methods of suicide prevention. This is an imperative for
those individuals that might be persuaded to proceed to elevated “suicide risk zones” (Alcantara
& Gone, 2007). With this brought to light, the identification of risk factors (i.e. factors that
increase the probability of a specific negative outcome) and protective factors (i.e. factors that
decrease the probability of a specific negative outcome in the presence of risk factors) within a
psychological, biological and sociological framework is crucial in revealing the points of
intervention and what determines any one individual’s capacity for suicidal tendencies
(Alcantara & Gone, 2007; Giles, 2013). It is also critical that these frameworks realize that
specific person-focused intercessions especially those which include the act of “victim blaming”
should be severely prohibited; instead the primary focus should be on the problematical and
complex interactions of the people and their environment (Alcantara & Gone, 2007). However,
the recent emphasis on suicide prevention endeavors has unfortunately been rather arduous and
has experienced delay in reaching Native American communities at the greatest risk. Optimistic
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results, though projected, are not warranted or secured (Alcantara & Gone, 2007). Freedenthal
and Stiffman (2004) findings suggest that there may indeed be a geographical based set of
factors that influence Native American communities either to or away from acts of suicide and
suicidal ideation. In their research of both reservation-based and urban-based individuals, there
was a statistically significant heightened level of suicidal ideation among those individuals who
had spent at least two-thirds of their lives on a reservation versus those individuals who had
spent at least two-thirds of their lives in an urban environment; however, Freedenthal and
Stiffman (2004) did find that their suicide attempts over their lifetime, both urban and
reservation-based individuals, was equal indicating that there may be an Indigenous cultural or
societal component connection to increased levels of suicide, suicide attempts, and suicidal
ideation. However, what was so strikingly different was the contrast in the inventories of risk
factors that correlated respectively with each of the urban-based and reservation-based samples:
Urban-Based Risk Factors for Suicide and Attempted Suicide found by Freedenthal and Stiffman (2004):
History of physical abuse
A friend attempting or completing suicide
Family history of suicidality
Reservation-Based Risk Factors for Suicide and Attempted Suicide found by Freedenthal and Stiffman (2004):
Depression
Conduct Disorder
Cigarette smoking
Low self-esteem
Family history of substance abuse
Lower perceived social support
Single-parent household
Perceived discrimination
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While very few studies with the exception of that by Freedenthal and Stiffman (2004), have
investigated and even considered “perceived discrimination” as it connects to suicidal actions
and tendencies. Discrimination, prejudice and conventional distress have been formerly cited as
risk factors for suicidal conduct and behaviors in Native American communities (Johnson, 1994).
Hill (2009) argued that ultimately balance, connectedness or disconnectedness within the
community, which is more often the case, is often at the core of the depressive and suicidal
behaviors among Native American populations.
Discussion:
Alcantara and Gone, (2007) described some of the more deeply rooted ecological and
generational origins of depression and suicide in Native American communities.
The legacy of colonization (referred to as historical trauma, soul wound, intergenerational
trauma, historical legacy, American Indian holocaust, and historical unresolved grief) has
been offered as a paradigm for understanding and explaining the alarming prevalence
rates of mental disorders and social problems—with much attention devoted to its role in
suicide—that have beleaguered Native American populations for generations both past
and present (Alcantara & Gone, 2007).
This literature review of the psychological, biological, and social risk factors for suicide and
depression in Native American communities demonstrates that the factors affecting and
influencing Indigenous persons to an elevated risk zone are intricate, deep and very complicated.
Risk factors for suicide and depression do not exist in seclusion; they exist intersectionally and
as an amalgamation of factors. It is a network of “genetic linkages, psychiatric conditions, Native
identity, social support networks, attitudes toward education, cultural continuity, spirituality, and
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socioeconomic factors” that are associated and interconnected with depression and suicidality in
Native American populations (Alcantara & Gone, 2007).
Beck, Walters, and Francisco (1990) argued that one of the most central concepts that
Native American people impart is the belief and connection to the philosophies of balance and
imbalance. Beck, et al. (1990) explained that “disease is seen as a part of the total environment
which includes the individual, the community, the natural world, and the world of ancestors and
spirits.” The problem is that the basic and fundamental methodologies, ontologies, axiologies,
and epistemologies of Native American populations are not being researched, investigated or
examined enough to meet an ever growing epidemic.
The academy educates and expects that its research will direct and control societal
renovation and change; however, when considering that the crucial and significant issue at hand
is that academic research has not shown or established that it can truly benefit Indigenous
communities. Instead the prospective “benefits” rarely, if ever, reach the Indigenous
communities or are used as deceptive maneuvers or strategies in order to pressure or compel the
communities into surrendering their traditional values, vacating their homes, being stripped of
their languages and being deprived of basic power over choices and judgments in their own lives
(Smith, 2012). Ultimately, the research academy “exists within a system of power” (Smith,
2012). There is an imperative demand not just for Indigenous research, but Indigenous
researchers to explore these matters of depression and suicide amid Native American
communities. It is fundamental that both Indigenous and non-Indigenous researchers should
create and establish an ecologically, culturally and ethnically sensitive psycho-bio-social
framework; this framework is not only essential in establishing much needed interventions for
depression and suicide, but to actually reduce the number of risk factors and to dramatically
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increase the number of protective factors available to Native American communities. The Native
American communities need an ecologically, culturally and ethnically sensitive psycho-biosocial framework that expresses and illustrates even the most elementary and deep-rooted belief
practices so that their culture and society can be restored to a place of balance, connection, and
unity.
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