What works here

Coping with Trauma in Indian Country

By Richard Manning

While Montana is gaining a reputation as a playground for the rich — complete with gated communities of multi-million dollar homes — the state also holds a distinct set of communities where the numbers tell a very different story: Unemployment approaching 70 percent in a state where the overall jobless rate typically is less than 5 percent, 80 percent of the population living below the poverty line, infant mortality rates far higher than the nation’s. All of this disproportionately afflicts children, the Native American children of the state’s seven Indian reservations.

A group of psychologists and educators at the University of Montana took up the case of these children more than five years ago, bringing to bear a standard treatment tool for children literally traumatized by the effects of poverty and violence. The methods have worked; the data show it, but they have also come to understand that their numbers and the usual social indicators tell but a small part of this story. There are layers of strength beneath the veneer of poverty.

The work has now expanded beyond Montana to reservations nationwide and is institutionalized at the university as the National Native Children’s Trauma Center. Its core processes developed in parallel with the evolution of thinking about all children in an increasingly troubled world. Richard van den Pol is the director of the university’s Division of Educational Research and Service, which includes the trauma center. He first came to the university in 1981 to deal with troubled preschool children, children often diagnosed then with attention deficit disorder. But in watching them, he became convinced researchers were missing something important. So did others, and over the next twenty years psychologists began to understand they need to pay a lot more attention to violence. The turning point was a series of shootings at schools, the archetype of which was Columbine High School in Colorado in 1999.

Child psychologists began to attach their thinking to a long line of research, not about children, but about soldiers. After WW I it was called “shell shock”, labeled “battle fatigue” after World War II, but not until the Vietnam War did it get its modern name, “post-traumatic stress disorder.” Children were suffering the very specific symptoms of PTSD.

“Without any apparent trigger, their bodies feel like they are out of control, just a sensation that ‘I am going crazy. My body is out of control, and this has never happened to anybody else’,” says van den Pol. The symptoms include patterns of intrusive thoughts, adrenaline rushes, fight or flight responses, withdrawal, and fear of crowds.

The attacks on the World Trade Center in September of 2001 crystallized this line of thinking, simply because a nation’s entire population of children was suddenly submerged in a constant replay of traumatizing images.

“Lots of little kids think fifteen or twenty jets crashed into the buildings simply because it was replayed again and again and again,” says van den Pol. “There was a clearly transformative point with nine-eleven when adults realized children were affected not only by being victims of, but also witnesses to violence.”

The problem is not so much the full on and debilitating range of symptoms that is PTSD, although there are children traumatized to that degree. The more widespread problem was children only partially afflicted, now an estimated 15-20 percent of the population overall, which is a lot of troubled kids. Of course, a disproportionate number of those live in poverty.

The pivotal work on this front occurred in Los Angeles, where researchers, among them Marleen Wong, developed a group treatment model based on cognitive behavioral theory. Working with a group of sixth-graders, inner-city students, mostly Asian and Hispanic, researchers developed a specific set of ten group and individual meetings that became known as “cognitive behavior intervention for trauma in schools.” It is now standardized with a very specific manual outlining the content of each session. The procedure began by standardized screening for trauma, then the eight-week intervention, then a repeat of the same battery of tests. Simply, the testing showed the kids got better.

Meantime, van den Pol’s group had already begun working with kids traumatized by specific outbreaks of violence. About this time, Wong approached him and asked him to apply what her group had learned in Los Angles to Native children in Montana. Van den Pol’s group won a federal grant to do so and began approaching reservation schools. Not long into the process, he heard an answer to one of his questions that was to inform much of the rest of the group’s work: “This is none of your business.”

In the 1880s, the Blackfeet, an important tribe that once claimed most of eastern Montana, suffered terrible seasons of smallpox. The U.S. Army, then among the Blackfeet, considered the resulting pile of bodies something of a resource and set a certain Z.T. Danial to work collecting skulls, which he shipped to the army museum. Each skull was a data point used by “researchers” to measure and support various racist theories based in cranial capacity. This collection of skulls eventually went to the Smithsonian, and the Blackfeet would regain them finally 100 years later to return them to Montana for proper burial.

This is not simply a 19th century issue. For instance, in a case widely publicized and discussed among Native communities in this decade, researchers from Arizona State University convinced Havasupai people to give blood samples for what they promised would be a study of diabetes, but then used the data to trace genealogy, something the Havasupai vehemently oppose.

The two incidents bracket a consistent history, many Natives believe, of researchers exploiting their poverty and isolation. In its simplest form, the objection is researchers use data, information that belongs to Indian people, to make money, a sort of violation of intellectual property rights. This objection applies even in cases such as the University of Montana’s work to help traumatized children, in that some Natives would say the children are simply fronts for a grant that maintain soft jobs for professors. This is an objection easy to dismiss if you don’t live in a community with 77 percent unemployment, and where most of those employed still live below the poverty line. From this vantage, a corner office with a computer, a desk and a paycheck look pretty good.

Van den Pol and his group had to rather quickly learn to respect these objections and designed ways to filter data so they could get the results they needed for further research, but still give the community control over the filter. Put another way, van den Pol learned the proper answer to, “This is none of your business,” which is, “It’s only my business if you decide it is my business.”

But this is simply the first slice of the issue. There are at least two more. To varying degrees both among individuals within a community but also from reservation to reservation, people practice traditional beliefs. These happen to be wholly relevant to treating traumatized kids in that traditional healing ceremonies can be an effective part of the therapy. Traditional leaders are highly sensitive to any of these matters being discussed in the outside world. Many of the practices are deeply personal, and people believe they derive some of their power by being closely held in community. They are nobody else’s business.

The problem is that, to the degree to which they are effective, they become a valid part of the treatment and therefore something researchers ought to report to their academic peers. In the academic world, science advances through shared information. But over the years, researchers have simply learned to make their peace with this issue. For example, traumatized kids can be overly attentive to noises, and part of the therapy can involve reasoning out the sources of noises that upset them: The wind, a car backfiring. But it is also acceptable in some traditional communities to say a spirit made the noise. When that happens researchers have learned to say something like: “I don’t know about that. You’ll have to ask someone who lives here.”

The second sore point over data is publicizing specific social indicators that show the scope of poverty, addiction and violence in a particular community. States like Montana with large Native populations on reservations have a long and continuing record of racism and stereotyping. Some of that data reinforces the stereotypes. In particular there are tensions and sensitivities among the various reservations. At times — recent times — some of the tribes have been bitter enemies. The Blackfeet and Salish were enemies before whites arrived. None of the tribes wants to see numbers published that make their community look worse than another.

Nor is such publicity necessary to do the work that needs to be done, so researchers have learned not to identify specific communities, schools or individuals. It is a convention this article will respect and in places be vague because some of this is none of our business. Besides, the trade-off is rich on the other end, first because kids get better, but second, because all of us can get a bit better if we pay attention to what is going on here. We begin to see this first by putting aside what is prohibited and seeing how engaging Native communities enriches our thinking.

If you have been on the high plains of Montana it is easy enough to empathize with Marleen Wong, who developed her work in the nation’s biggest city then suddenly found herself in a car headed across the prairie. It is a treeless land of rolling hills, a fact that, in itself, can be disorienting to the uninitiated. For instance, there is the example of a first-time visitor to this place who walked a short time on the plains and immediately became dizzy and disoriented from a lack of vertical referents. He had to stand next to and hold on to a car until he felt better. Then there is the fact that much of this place is in something like its original condition, and so its history often seems to ripple through the air like muttering voices of ghosts. Part of this is the highly unpleasant history of genocide of these people in this place, and they know this.

But what Wong found most disorienting in that first meeting on one reservation was it was not a meeting, but a “talking circle,” called by the community to discuss the very recent killing of a young man by another young man who happened to be his relative. Everyone in the room knew both victim and killer, and this is not at all an uncommon event here. Wong then knew she was in a different world with different rules.

“When one works in a tribal community, you cannot separate yourself. There isn’t a distinction between a professional or a leader. Those roles are very difficult to maintain,” she says. “In the talking circle, you are asked to speak from your heart….not in your role, but what this means to you. I guess that is what makes it so powerful.”

At the time, Wong had recently lost her own sister to cancer and found herself sharing the grief of her Chinese American family with a circle of Montana Indians. As a result, it became quickly apparent that adapting to this place was far more than meeting a few idiosyncratic sensitivities about data. The community was, in fact, not so much erecting barriers as demanding the academics drop some of theirs. Life in Indian Country, as we shall see, is all about relationships and the community was demanding that the researchers stop researching for a moment and engage in real relationships.

Wound up in this is a second anomaly that quickly emerged and reveals much of what we need to know about this story. Trauma, as it is generally considered, especially in the classic cases among soldiers, is a response to a violent event, often, a specific violent event. That too was the case with Wong’s work in Los Angeles. The troubled kids there had often witnessed something like gang violence or a street killing. In fact, Wong has mapped street violence and correlated it with locations of schools for a revealing picture of the world these children inhabit. When researchers began screening Indian kids in Montana, they found that indeed they were suffering from trauma, but on questioning them, the children reported the bad feelings were related to loss, not violence, usually the death of a close relative. Opinions as to why this is true vary among van den Pol’s colleagues, both white and Native, but there is a sort of consensus. First, this phenomenon is real and an important distinction in revealing the world in which these children live, especially the importance of relatives. And second, it is not real, but covering some uglier truths, also having to do with the importance of relatives.

The foundation of the sadness in most of these children is something some people call “cultural grief.” This is difficult to understand in our polyglot world of fragmented cultures, but within an Indian reservation, real enough, and not at all unique to Native Americans. Something similar endures among holocaust survivors, for instance. Native people are aware of their history and it is readily accessible here, not so long ago, and seeming closer than late 19^th century in a place not yet tamed. Nor did the troubles end with the genocide of the 19^th century. In the 20^th, Indian policy was dominated by the boarding school system, which meant many of these children’s grandparents were rounded up and shipped off to boarding schools hundreds of miles away to strip them of ties to their families and culture. They were physically punished for speaking their languages and often abused. The resulting resentment accrues from generation to generation.

In fact, much more than culture is wound up in inter-generational trauma. For instance, as I write this in mid-2009, the biochemist Rachel Yehuda is about to publish a groundbreaking paper. She has long studied holocaust survivors and intergenerational trauma at the Mount Sinai School of Medicine in New York, searching for a genetic link for trauma. Researchers had suspected such a link existed, simply because trauma seems to run in families. She, in fact, found no genetic link and demonstrated the intergenerational ties are not between children and parents, but between children and mothers, and it is chemically transmitted. Traumatized women develop a unique biochemistry that stops an important gene from functioning, the gene that generates the chemical cortisol, which allows normal people to return to normal after a traumatic event. That biochemistry transfers to infants in utero. Technically, the tie is not genetic, but epigenetic. Kinship ties can cut both ways, but in Indian country, kinship ties count for much more than a bit of chemistry.

Often, a grandparent or an uncle serves as a child’s real tie to this culture. They bear the stories and so when one of these people dies, a bit of personal history dies with him.

Besides, these children have a very different idea of family. All the brothers and sisters of one’s biological grandparents are regarded as grandparents as well, and addressed that way. It is said here that one treats his cousin like a brother and his neighbor like a cousin and there is no one more remote than neighbor. Households are not nuclear families and often hold several generations and cousins as well as brothers and sisters.

There is indeed a downside to all of this. Every Indian kid is intimately tied to many people and most take these relationships seriously. Couple that with the high death rate on reservations, and the product is that most kids go to four or five funerals a year, a fact in itself upsetting.

Yet those funerals are major events, grieving involving most of the community. In some communities, the school’s gymnasium is the biggest room available, so often wakes occur at the schools. Death permeates their lives.

But often, an auntie or a grandparent has become a child’s protector, surrogate parent sought out by the child for understanding and affection. These individuals serve as a refuge in families full of violence and drug abuse, and when one of them dies, a child loses that refuge.

Marilyn Zimmerman is Native and has lived for the past forty years on a reservation in Montana. She has a master’s degree in social work, has worked extensively in suicide prevention and is now on the staff of the trauma center. She agrees trauma is more complicated in Native communities.

“American Indians experience chronic losses from very young ages to very old ages. People die a lot, and people who are important in their lives die a lot, and when someone dies in one family the ripple effect to the community is profound because we are related,” she says.

Patricia LaPlant was active in Native politics at the University of California at Berkeley in the 1970s, part of the protest that occupied Alcatraz Island. So was her husband, who is also a Vietnam War veteran. Both are Blackfeet, and they returned to the tribe’s reservation about twenty-five years ago. She raised her eight children there and worked all the time in social work and on mental health issues. She finished her master’s degree in social work at the University of Montana and is at work on her PhD. She is on the staff of the Native Children’s Trauma Center.

Asked about the general sadness of children in her community, she does something most professionals don’t, goes straight past the mask of anonymity to talk about her own grandchildren.

“I always say my own children have more dead friends than I do because of the accidents,” says LaPlant, a fact she blames on widespread drug use, especially crystal meth and prescription medications. The spin-off is violence, both domestic and otherwise and crashes on the highway that take young lives.

But then she narrows the case to her own granddaughter, a young woman with a close family connection to a skilled mental health worker. She says despite that advantage, her own granddaughter is lost in a sadness of the sort that endures across generations.

A therapist in another community offers another explanation for the extra burden of Indian grief. Grieving practices vary widely across the communities, but in one, there is a firm rule. Relatives are allowed, in fact, encouraged, to express deep emotion throughout the three-day funeral, but when the body goes into the ground, the crying must stop, even among children. The belief is that the spirit would see people crying and would believe her leaving provoked undue sadness, so would not continue on in her journey. The children suppress grief. That is to say, the web of kinship and connection makes children responsible not just to an enormous network of living relatives, but to the dead as well.

Yet LaPlant and most of her colleagues think this focus on grief is a cover-up. First, it is thought to be simply impolite to mention certain things in her culture. “It’s outright rude to ask someone to tell a personal story in an impersonal setting about something that is so hurtful and meaningful,” she says.

Talking about grief is allowed, so kids will often use it as a surrogate for what is really bothering them. But more importantly, these children often have been traumatized by family members, and a relative, in their world, is a very important thing. An uncle may be a crystal meth addict who beats his girlfriend, but a relative all the same. LaPlant says the kids know full well there are offenses teachers and counselors are required by law to report, and reporting would bring a measure of shame, not to mention, hardship, on the family.

In one community, a woman’s boyfriend was abusing her children and the woman was being held accountable by law enforcement for not protecting them from that abuse. So those children were removed from their mother’s care, despite the fact she was not the abuser. Kids know these stories and learn a code of silence.

The paradox in all this lies in a set of parallel assertions that emerged in one conversation with a group of school counselors. Once in the interview, one said that when a snowstorm comes in the middle of the school day — not uncommon in the tundra-like winter of the northern plains — school officials aren’t worried about sending kids home, even where parents are absent. Every kid has a nearby home where he can go and be welcome, even expected by a relative or someone who behaves like one. All in the interview agreed.

At another point, a group member cited the same circumstances, and said school officials try to keep school in session until the end of the day, snowstorm notwithstanding. The fear is, some children will have to go to a relative’s home, where they might be harmed or abused. All in the interview agreed. Kinship cuts both ways.

LaPlant says there is no mystery to the cognitive behavior routine used in the program. The methods, in fact, resemble traditional practices that look very much like the routine specified as cognitive behavioral intervention therapy in schools.

She and others say that the routine, as developed and delivered from Los Angeles, had to be modified for a number of reasons, especially because it was, in places, simply too blunt. This modification — both of the routine, but also the university’s approach to the community — was the focus of the early going of the program, a process the group called then “cultural adaptation,” until LaPlant said in one meeting that she was put off by the term. So the group began thinking more deeply about what was going on, and talked to a couple of traditional Blackfoot healers from Canada about the tussle with nomenclature. As has happened before and since, the pair leapfrogged any academic obfuscation by suggesting the therapists were not so much seeking a name as a method that works. So why not call it “what works here.”

What they are doing does work, and the data are pretty clear on this after five years of experience in some communities. As in Los Angeles, the counselors first use standardized tests to screen for PTSD and assess depression. Those with full-on PTSD are sent to therapists for individual treatment. The group intervention is meant for those with milder symptoms. Likewise, there is an initial screening for children traumatized by sexual abuse, and they too get individual treatment. The routine is a group intervention and telling stories of sexual abuse in a group would violate privacy, especially in a place where everybody knows everybody else.

Then the remaining candidates attend a series of both group and individual meetings over nine weeks. They are first taught some very specific coping skills, especially deep breathing exercises that help calm anxieties. Then they are urged to identify the situation that causes their trauma, then revisit it, each time more thoroughly and practice the skills that help them cope. When they complete the course, there is a formal graduation ceremony, often attended by a tribal elder.

“We are working with a trained therapist exposing them to a trauma trigger over and over and over again until we wear it out,” says van den Pol.

Often that can involve allowing the children to tell their trauma stories to the rest of the group, but early on, therapists recognized they had an especially effective tool. Indian kids seem to like to draw and the process became, quite literally, graphic. When they are describing this phenomenon the therapists light up, hands start to talk in the air, and eyes flash. One therapist tells of a child drawing a picture of a traumatic scene complete with a depiction of the child’s emotion permeating the air, and the therapist said she could recognize the angst the child had drawn.

But another tells of a child drawing a funeral, at first a rudimentary sketch, but in succeeding weeks revisiting that same drawing, over and over again, adding layers of detail, first who and what was there, then more scene, then adding food and smells. If those who had designed the therapy could have thought of a single picture that describes the process, this is it.

In each case, the process seems to be one of filling in the important blanks. One therapist gives the example of a student who suddenly became quiet and withdrawn and all of a sudden unable to go to music class, something most kids enjoy. She began puzzling over what it might be about music class that so disturbed this child. Then she simply retraced with the child the steps to music class and found the route passed by the kindergarten classroom where the cubby held a coat rack of toddlers’ winter clothes. These reminded the girl of a younger sibling who had just died. Toddlers’ clothes were her trauma trigger. For another child, it was the color turquoise, because her mother had been wearing a turquoise shirt when she was last badly beaten and bloodied.

In the end though, the results of all this are not terribly dramatic, just a solid, reasonable and workable step toward making kids better, and that may be the most important point. Given this, it probably is an academic exercise to argue whether these kids are suffering grief from normal loss or trauma from violence and are papering over it with stories about grief. No matter what the reported cause, the intervention builds skills for dealing with trauma, and given conditions of their lives, trauma will surely come.

David Schuldberg is a licensed psychologist with a PhD from Berkeley, teaches at the University of Montana and is the evaluator of the Native Children’s Trauma Center, a wholly inadequate description. Better to say he is animated and engaged. He’s a self confessed, died-in-the-wool data guy firmly rooted in academia, and he doesn’t have to move far off that position to evaluate the trauma program.

“What the data are saying is our preliminary efforts to do cultural adaptation is maybe working,” he says. I.e. it works here.

And maybe when he first became involved with the program he might have stopped there, but Schuldberg expands his engagement with the program to two different levels. The first is rooted in an event at a reservation outside of Montana. He and a colleague, Gyda Swaney, who is Salish, traveled there to assess a community battered by an epidemic of suicides, a serious epidemic. Yet they were not being called in to stop it. The Native people had already done that with a traditional ceremony, and it worked, and that really doesn’t push Schuldberg past his comfort level as an academic.

Those sorts of treatment methods he regards as classic “black box” experiments. He doesn’t need to know what is going on inside the box to measure data on each end.

But Schuldberg readily acknowledges that the demands of Native communities have pushed him beyond his comfort level and this is his favorite part of the program, an effect so common he has come to call it “being in deep water.”

The culture clash here is not so much white-Native as it is academic-Native. His experience has taught him Native people can have a very different way of seeing the world. There is an ineffable element to this, a sort of mystery.

“This is one of the favorite things I do…. because it’s so profoundly teaching to me,” he says. “All the time there’ll be these situations where I’m like ‘oh my’.” Then he quotes an old Bob Dylan song, the Ballad of the Thin Man: “Something is happening here and you don’t know what it is, do you, Mr. Jones?”

Yet there is another element of this that is not so mysterious, and can be as simply put as saying Native people are teaching academics good manners, or even good research. Academics, data driven as they are, can behave like doctors with bad bedside manners. Sweep in and suck up vital signs without caring about the patient, a process Schuldberg calls “drive-by research.” The barriers erected early in the program by Native communities really forced the program into something more enduring, creating relationships, as Wong found out, forcing researchers to give something of themselves to the process.

“I’m trained as an academic in the classic university model. Stand and deliver is what I like to do. It’s really hard for me to shut up and listen, and that’s what you need to do,” Schuldberg says

Shut up and listen. Drive-by research is not only bad for communities; it’s bad for research.

Van den Pol says he began to learn this lesson when he sent Aaron Morsette, a graduate student and Native who has since earned his PhD using the program as a foundation, to gather data in one community. Instead of diving straight into the task, Morsette “shot hoops” for awhile. Van den Pol says that, as a result, he came back with a wealth of relationships, as well as data.

In that process of listening, researchers have uncovered and begun to ruminate on a curious fact, measurable in data. As paradoxical as it may sound, Native people return to live on reservations, even those with the means to go elsewhere. Swaney sums this effect as “resilience,” that despite all the hardships, people are attached to their people and place. The data measure this because researchers have shown that while kids in the program get dramatically better, kids screened twice, months apart, before entering the program also get better, just not as much. Some take this as a measure of the resilience already present in the community, that the program is not so much causing improvement as it is catalyzing it.