‘A struggle for hope‘

Different tribes, different languages, but a common thread: despair.

After generations of displacement, forced assimilation, poverty and neglect, many American Indians are trapped in a cycle of hopelessness that often leads to substance abuse, violence and in many cases suicide, say experts. In fact, according to the Indian Health Service, the suicide rate for American Indians is two and a half times higher than the national average. The rate for Indian youth and young adults 15 to 24 years old is over three times higher than the national average for this age group.

But there appears to be a glimmer of optimism for this long-ignored population. Community leaders, Indian psychologists and government agencies such as the Indian Health Service and the Substance Abuse and Mental Health Services Administration are working to identify the factors that contribute to suicide and to design interventions to help prevent it in those most at risk.

"The suicide rate did increase markedly in the 1970s and 1980s and then leveled off at very high rates," says psychologist Jon Perez, PhD, former director of the Behavioral Health Unit of the Indian Health Service (IHS). "However, now it's looking like there might be some hope that we can attenuate the rate."

New federally funded programs and tribal initiatives are working to do just that. In 2003, the IHS established its Suicide Prevention Committee, which established a national network with 50 to 60 people who train communities in how to prevent and react to clusters of suicides, which have become a frequent problem on reservations.

Also, last year the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it was providing $9.6 million in grant money over three years for eight youth suicide prevention programs, many of which target American Indian and Alaska Native communities. SAMHSA also recently awarded $49.3 million in grant funding for 14 new and one supplemental grant to tribal organizations for mental illness and substance abuse prevention, treatment and recovery support programs. The tribes will use the grants to fund culturally appropriate programs addressing issues such as suicide in schools, programs for children with severe emotional disturbances and alcohol- and methamphetamine-abuse prevention programs.

These programs will embrace methods specific to each culture, drawing on native traditions to promote understanding and healing.

A history of trauma

Many Indian psychologists believe that the root of the population's suicide problem is the combination of generational trauma and loss of ethnic identity.

As psychologist Tawa M. Witko, PhD, notes in her book, "Mental Health Care for Urban Indians: Clinical Insights From Native Practitioners" (APA, 2006), Europeans' effort to "civilize" Indians changed their culture in ways that are still being felt. In fact, until a generation ago, Indian children were still taken from their families and tribes and sent to boarding schools to assimilate into white culture. In the process, many customs that should have been handed down from generation to generation have been lost, notes Witko.

The intergenerational trauma, compounded by extreme poverty, lack of economic opportunity and widespread substance abuse, has shattered these communities, Perez says. "Suicide is a single response to a multiplicity of problems," he emphasizes. "If you have these things going on, and you don't see any hope for the future, suicide seems like an option."

Hope can often be hard to come by when there are not enough jobs on the reservation and you don't have a car or enough money for gas or even food, says Diane Willis, PhD, a Kiowa tribe member and professor emeritus at the University of Oklahoma Health Sciences Center. Willis, who has worked with tribes across the country teaching locals about infant mental health, says the economic situation is so dire that some Indians are starving. At one reservation-where the average resident income is $2,900 a year-she saw an 18-month-old little girl who was so hungry, that she grabbed for a freshly poured bowl of soup and burned herself. At another reservation, 40 people had attempted suicide within the last six months and approximately half succeeded.

Substance abuse-particularly alcohol-has fueled and compounded the misery, says psychologist Marlene EchoHawk, PhD, a member of the Otoe Missouria tribe and director of the Indian Health Service's Suicide Prevention Committee. In her community, alcohol became more prevalent when young Indian men returned from World War II with a newfound taste for alcohol and suffering from what is now recognized as post-traumatic stress disorder. They used the alcohol to stop the pain, but it only increased the depression, notes EchoHawk, who has seen this pattern repeat itself with tribe members returning from Vietnam and now from Iraq.

Young people in Indian communities are turning to alcohol at a very young age, setting them up for a lifetime of alcohol abuse and an increased risk of suicide, says Willis. Indeed, in one community, almost 20 percent of middle school students admitted to having attempted suicide in the last six months, psychologist Teresa LaFromboise, PhD, an associate counseling psychology professor and chair of Native American Studies at Stanford University, found in a recent survey.

"Our children and grandchildren are carrying all the pain of the generations that came before," says Ethleen Iron-Cloud Two Dogs, a member of the Ogalala Lakota tribe and director of Wakanyeja Pawicayapi (The Children First), Inc., a non-profit community mental health organization on the Pine Ridge Indian reservation in South Dakota.

Hope in a return to tradition

Historically, suicide was rare in American Indian culture, and the stigma attached to it is still very strong, notes LaFromboise. Many communities are just now coming out of denial and starting to address the problem, she adds.

Because the community emphasis on suicide is relatively new, there isn't a lot of research on what works. Many of the SAMHSA-funded programs will use evidence-based practices and tailor them to community culture and needs.

Indian psychologists believe that letting the community determine what it needs and allowing residents to incorporate traditions will produce the best results.

Indeed, community-oriented suicide prevention can significantly decrease suicidal gestures and acts, sociologist Philip A. May, PhD, found in a 15-year study published in the American Journal of Public Health (Vol. 95, No. 7, pages 1238-1244).

"We do have strength and we do have resources," maintains Shannon Crossbear, a member of the Ojibwe tribe and of the board-which Iron-Cloud Two Dogs is also vice president of-at First Nation Behavioral Health, a mental health advocacy group for American Indians and Alaska Natives. Her community has revived coming-of-age ceremonies for young girls, and in the short time they have been doing it, they have seen changes like fewer girls getting pregnant at a young age and greater engagement in community rituals.

EchoHawk's tribe has started performing a ceremony that emphasizes spirituality and reintegrating into the community for those returning from Iraq. In the IHS youth centers, they are also using traditional practices where possible, and the young people are using them, she adds.

LaFromboise developed the American Indian Life Skills Development Curriculum, designed to reduce suicidal and other destructive behavior by giving students coping and problem-solving skills. The curriculum addresses specific problems in Indian students' lives such as substance abuse, dysfunctional family environments and violence, and builds self-esteem by encouraging students to learn about and take pride in their cultural heritage. In the process, students also learn how to help a suicidal friend get help within the community. The program, initially developed for the Zuni tribe in collaboration with the Cherokee Nation, has been adapted in several other communities.

In communities where there have been clusters of suicides, the solution appears to lie not within clinical methods, but in the response of the community itself, says Perez. How quickly and effectively they respond has been a much better predictor of reducing suicide rates than any clinical methods outside agencies have provided. Economic empowerment is also critical, adds Willis.

Traditionally American Indians are taught to view neighbors as family, notes Crossbear, and this can be an essential strength.

"In American Indian communities we have to be family," she says.