INTRODUCTION We have already paid the price. It’s time to accept the many blessings that the creator has in store for us. We must honour our people who sacrificed everything through honouring ourselves and healing ourselves. By healing ourselves, we will also heal the wounds of our ancestors and the unborn generations. 1 Canada is well-known for enjoying a high standard of living–among the best in the world–and for being an international leader in the theory and practice of health promotion. Canada has also been criticized be- cause the health of Aboriginal Peoples in this country resembles that of people living in economically dis- advantaged and underdeveloped countries. Aborigi- nal people die earlier than non-Aboriginal people and have a greater burden of physical and mental disease. 2 However, the reasons for this health in- equality are not well understood. In this paper, the authors discuss the importance of acknowledging and addressing historical and intergenerational trauma in Aboriginal communities. Systemic racism, policies of assimilation, and cultural genocide are rarely identi- fied as critical to contemporary health crises. Post- traumatic stress as a result of loss of culture and his- torical as well as intergenerational trauma is presented as an explanatory factor for the largely un- examined question of why gross health inequalities exist. HEALTH STATUS OF ABORIGINAL PEOPLES Issues of equity in health and well being for Canada’s Aboriginal peoples are important to any vision of a just society. 3 14 Journal of Aboriginal Health • March 2005 Healing the Generations: Post-Traumatic Stress and the Health Status of Aboriginal Populations in Canada Terry L. Mitchell, PhD, C. Psych., Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, and Dawn T. Maracle, MA, Ontario Institute for Studies in Education, University of Toronto, Ontario Abstract The enduring impact of colonization and loss of culture are identified as critical health issues for Aboriginal populations. The authors discuss the concepts of historical and intergenerational trauma identifying steps to address the past as Aboriginal Peoples move forward to a healthy future. The authors analyze the enduring and unacceptable health inequalities between Aboriginal and non-Aboriginal people in Canada. This paper emphasizes the importance of addressing the substantial historical reasons for this inequality. The authors suggest that current popular explanations for such gross differences in health are limited and lack substantive historical perspective. Post-traumatic stress disorder is discussed critically as an important concept for understanding Aboriginal health inequalities. Post-traumatic stress response, versus disorder, is presented as a less stigmatizing and potentially culturally-appropriate framework to view the inequalities in a historical and political light. A historically and politically-based stress response is proposed as a framework for understanding the health inequities between Aboriginal and non- Aboriginal people to advance healing for indigenous people worldwide. Key Words Aboriginal, post-traumatic stress disorder/response, culture, residential schools, health, colonialism, historical trauma, intergenerational impact
Transcript
INTRODUCTION
We have already paid the price. It’s time toaccept the many blessings that the creator hasin store for us. We must honour our peoplewho sacrificed everything through honouringourselves and healing ourselves. By healingourselves, we will also heal the wounds of ourancestors and the unborn generations.1
Canada is well-known for enjoying a high standardof living–among the best in the world–and for beingan international leader in the theory and practice ofhealth promotion. Canada has also been criticized be-cause the health of Aboriginal Peoples in this countryresembles that of people living in economically dis-advantaged and underdeveloped countries. Aborigi-nal people die earlier than non-Aboriginal people andhave a greater burden of physical and mental
disease.2 However, the reasons for this health in-equality are not well understood. In this paper, theauthors discuss the importance of acknowledging andaddressing historical and intergenerational trauma inAboriginal communities. Systemic racism, policies ofassimilation, and cultural genocide are rarely identi-fied as critical to contemporary health crises. Post-traumatic stress as a result of loss of culture and his-torical as well as intergenerational trauma ispresented as an explanatory factor for the largely un-examined question of why gross health inequalitiesexist.
HEALTH STATUS OF ABORIGINALPEOPLES
Issues of equity in health and well being forCanada’s Aboriginal peoples are important toany vision of a just society.3
Terry L. Mitchell, PhD, C. Psych.,Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, and
Dawn T. Maracle, MA,Ontario Institute for Studies in Education, University of Toronto, Ontario
Abstract
The enduring impact of colonization and loss of culture are identified as critical health issues forAboriginal populations. The authors discuss the concepts of historical and intergenerationaltrauma identifying steps to address the past as Aboriginal Peoples move forward to a healthyfuture. The authors analyze the enduring and unacceptable health inequalities betweenAboriginal and non-Aboriginal people in Canada. This paper emphasizes the importance ofaddressing the substantial historical reasons for this inequality. The authors suggest that currentpopular explanations for such gross differences in health are limited and lack substantivehistorical perspective. Post-traumatic stress disorder is discussed critically as an important conceptfor understanding Aboriginal health inequalities. Post-traumatic stress response, versus disorder, ispresented as a less stigmatizing and potentially culturally-appropriate framework to view theinequalities in a historical and political light. A historically and politically-based stress response isproposed as a framework for understanding the health inequities between Aboriginal and non-Aboriginal people to advance healing for indigenous people worldwide.
Despite tremendous progress, the health of theAboriginal population in Canada continues to be sig-nificantly poorer than that of the national population.4A recent report on the Health of Off-Reserve Aborigi-nal Populations5 found that Aboriginal people are 1.5times more likely to have chronic health conditionsand long-term restrictions on their activities than non-Aboriginal people. About 60 per cent were reported tohave at least one chronic condition. High levels of di-abetes and end-stage renal disease, cardiovascular dis-ease, and some forms of cancer as well as injury andpneumonia6 have been identified as more common inAboriginal populations than the general Canadianpopulation. Mental health issues or issues of imbal-ance are reflected in high levels of depression, addic-tion, and suicide rates.7
Health Inequalities
There are enduring and unacceptable inequalities inthe health of Aboriginal Peoples. The authors proposethat there is a real, yet largely unaddressed, historicalreason for these health inequalities. Mental health andsocial problems in Aboriginal communities have beenlinked to social and cultural disruption and historicaltrauma. However, the physical health of the popula-tion has not been adequately nor consistently linked tothe historical and social-political context of the livesof Aboriginal people. This failure to remember andhold significant the history and long-term impact ofdomination and cultural genocide has led to limita-tions in current explanatory frameworks and to inade-quate health interventions.
As a whole, Aboriginal populations still sufferfrom gross social and economic inequalities com-pared to non-Aboriginal Canadians. Many Aborigi-nal communities suffer incomes well below thepoverty line, high levels of unemployment, low ratesof high school completion, and inadequate housing(20 per cent of Aboriginal communities in Canadastill have limited or no access to clean water).8 So-cial and structural injustices compounded by unequalaccess to health information and services all con-tribute to the striking differential in health status be-tween Aboriginal and non-Aboriginal populations.However, recent evidence from Statistics Canadabased on data from the Canadian 2001 CommunityHealth Survey has identified that the severe healthinequities endured by Aboriginal populations cannotbe accounted for simply in terms of low socio-eco-nomic status,9 as is often suggested when discussingthe health of Aboriginal Peoples. They also cannotbe accounted for in health risk behaviours that frame
health status within an individual’s control. This isan important finding, one that challenges an individ-ualistic approach to health inequities. That is, thehealth status of Aboriginal Peoples cannot be attrib-uted solely or even largely to poverty or to individ-ual choices and lifestyles, a common and limitingone-dimensional way of looking at issues of Aborigi-nal health.
This brings the key question of this paper into fo-cus. What contributes to the enormous difference inhealth status between Aboriginal and non-Aboriginalpopulations? Despite extensive documentation of thehealth and social problems within Aboriginal commu-nities, inadequate weight and attention outside ofAboriginal communities themselves has been given tothe root source of these problems. By raising thequestion of historical stressors10 and post-traumaticstress responses (PTSR) as critical to an understand-ing of current health status, the authors do not attemptto provide a simple solution to a complex and endur-ing challenge for Aboriginal communities. Rather, theauthors wish to challenge the policies, programs, andhealth-funding strategies that fail to ask why this dif-ferential in health status exists and how it can be ad-dressed in a timely manner. The question is no longer,What are the problems? The more appropriate ques-tions are: Why do these differentials exist? What willbe done to address these health inequities? What aresuccessful models? and How can we implement themmore widely?
Loss of Culture, Historical Trauma, andUnresolved Grief
Articles on the health of Aboriginal people discussthe experience of collective and intergenerationaltrauma that has been referred to as the Native holo-caust11 and/or soul wound. The chronic trauma ofboth post-traumatic stress and intergenerational ef-fects has been identified as historical trauma.12 His-torical trauma is referred to as collective emotionaland psychological injury over the lifespan and acrossgenerations. It is viewed as resulting from a history ofgenocide with the effects being psychological, behav-ioural, and medical.13
Historical trauma response has been identified as agroup of reactions to multigenerational, collective,historical wounding of the mind, emotions, and spirit.Historical trauma for Aboriginal populations is un-derstood to be linked directly to the banning of cul-tural practices, policies and institutions of assimila-tion, and loss of culture. This is described as aprocess in which previously strong cultural identities,
Journal of Aboriginal Health • March 2005 15
rooted in traditional practices and world views, weredevalued and replaced by cultures of dependence andimbalance.
… under the relentless influence of forced as-similation, economic dependence and isola-tion, Aboriginal cultures have undergone aprocess of deculturation. Evidence for thisprocess of cultural degeneration is found insuch phenomena as alcoholism, substanceabuse, suicide, family violence, sexual abuse,child neglect, vandalism and theft, all ofwhich are epidemic in many Aboriginal com-munities. It is paramount to notice that noneof these indicators of cultural and identity de-generation characterized pre-colonized Abo-riginal culture.14
Deculturation, or cultural degeneration and loss,and related historical trauma are identified as leavinga “legacy of chronic trauma and unresolved griefacross generations.”15 This devaluing and loss of cul-ture has had long-term and intergenerational effects. Itraises critical health challenges including new epi-demics of injuries and social problems for Aboriginalcommunities. These have been identified as more dif-ficult to address than the infectious diseases that his-torically killed many Aboriginal people and dramati-cally reduced the population of Aboriginalcommunities.16 The compounding trauma of culturaldevaluation and loss and social ills is therefore impor-tant to assess in attempting to understand the currenthealth crises within Aboriginal populations.
POST-TRAUMATIC STRESS AS APOTENTIAL FRAMEWORK FOREXAMINING HEALTH DIFFERENTIALS
You don’t come with guns anymore; youdon’t have to. You come with briefcases andwe kill ourselves.17
Post-Traumatic Stress Disorder Defined
Post-traumatic stress disorder (PTSD) was first in-troduced into the American Diagnostic and StatisticalManual (DSM) in 1989.18 Post-traumatic stress arisesfrom external trauma and terrifying experiences thatbreak a person’s sense of predictability, vulnerability,and control.19 Aboriginal Peoples’ experiences of con-tact and cultural domination may reasonably be
viewed as a loss of predictability and control and in-creases in vulnerability. As a case in point, a report onthe mental health needs of 127 survivors of residentialschools in British Columbia20 found that 64.2 per centof these individuals met the diagnostic criteria forPTSD.21 While these individuals may have been moreaffected than others, as they were motivated to endurethe hardships of court proceedings, there is neverthe-less an important validation of the potentially highrates of post-traumatic stress in Aboriginal communi-ties that have suffered the abuses of residentialschooling.
In the United States, considerable research hasbeen done on the issues of PTSD and intergenera-tional trauma. Historical trauma and unresolved griefhave been identified as key issues for Native Ameri-cans.22
While not all Aboriginal people experience post-traumatic stress, current health inequalities suggestthat historical trauma should at least be consideredduring diagnosis and treatment. The diagnostic crite-ria for PTSD include exposure to an external traumathat results in intense fear, helplessness, or terror thatendures for 30 days or more and results in significantsocial or occupational distress. PTSD affects individu-als in a vicious cycle of denial, avoidance, and be-coming overwhelmed with memories and related feel-ings. The impact of PTSD affects the mind, emotions,body, and behaviour. Mentally, people who are trau-matized may develop negative beliefs about them-selves and their world. Emotionally, they may experi-ence cycles of denial and anxiety. Physically, they canexperience sleep disturbance, heightened sensitivityand anxiety, nightmares, and flashbacks. Behav-iourally, they may avoid certain situations, isolatethemselves socially, drink, and become increasinglyaggressive. The three main characteristics of a PTSDaffect the mind, emotions, and the body. The mind isaffected by re-experiencing through dreams, flash-backs, unwanted memories, and repetitive thoughts.The emotions are affected by avoidance and numbingsuch as avoiding social contact, avoiding memorytriggers, using alcohol or drugs to numb, and dissocia-tion. The body is affected by exaggerated startle re-sponses, sleeplessness, and anxiety.
Four Factors Regarding ConceptualRelevance of PTSD to Aboriginal Health
While there is little representation of Aboriginalpeople in large population health studies on post-trau-matic stress to date, post-traumatic stress has beenused as a culturally-appropriate marker for Aboriginal
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16 Journal of Aboriginal Health • March 2005
distress.23 Despite the generally negative associationsociety has with psychiatric diagnoses, the authorscautiously suggest that the diagnostic criteria forPTSD provides a useful model for beginning to un-derstand the reason for the gross health inequities be-tween Aboriginal populations and the non-AboriginalCanadian population. PTSD has been criticized as apsychiatric term that “individualizes social problemsand pathologizes traumatized people.”24 The authorsargue that the uniqueness of the PTSD diagnosiswithin the DSM contradicts this criticism. The authorspropose that the diagnostic profile provides a usefultool in confirming the long-term impact of colonial-ization, which may increase access to appropriatehealing resources.
While the PTSD criteria were defined in terms ofindividual trauma, the diagnosis and treatment re-sources have also been applied to groups or popula-tions affected by natural and man-made disasters andterrorism. The work of Eduardo Duran et al.25 haspaved the way to understanding and responding totrauma at the community and nation level. The au-thors agree with Bonnie Burstow26 that healing fromtrauma should take place outside of a psychiatricframe and that a program of radical adult educationwill focus on strengths and capacities rather than ill-ness. This is an existing practice of leading PTSDhealing programs that are grounded in respect andsupport rather than blaming or focussing on weak-nesses and illness.27
While the authors disagree with the use of theterm “disorder,” they believe the PTSD framework isan important model to consider in assessing the rea-son for and potential responses to current health in-equalities. Post-traumatic stress is unique as a mentalhealth diagnosis because one cannot meet diagnosticcriteria unless there has been exposure to a traumaticevent. What is observed among people who havebeen traumatized, therefore, is not a disorder butrather a stress response to horrific, intolerableevents. The source or cause of the stress responsehas been defined as a traumatic event or series ofevents that occur outside the individual rather thanresulting from an inherent psychological weakness.While the authors are cautious about suggesting anassociation with a psychiatric term in relation to thehealth of Aboriginal populations and specificallywith the use of the terminology of DSM disorders,they find the unique criteria of PTSD worthy of re-view as a framework.
Firstly, PTSD allows for the naming of externallyimposed trauma providing a social-historical context
for what has too often been viewed as behaviours orconditions rooted in individual character flaws or cul-tural deficits.
Secondly, PTSD is useful in an Aboriginal healthcontext because it defines an individual’s behaviour asa human response to an external traumatic eventrather than a personal weakness or pathology. Thefundamental claim is that the person is not to blamefor their traumatic experience nor their symptoms.Post-traumatic therapy assumes that the patient’s cur-rent emotional problems are caused by the traumaticevent rather than by an already existing mental illness.Stress reactions are identified as normal patterns ofadaptation to extremely stressful life events. Post-traumatic therapy involves educating people about thenature and experience of stress responses, “which re-duces a sense of isolation and fear of mental illnessand restores a sense of personal control over symptommanifestation.”28 The individual or group and thetherapist work together to create a safe and supportiverelationship in which healing can occur and humandignity and peace with and within oneself can be re-stored.
Thirdly, PTSD is a reasonable explanatory modelfor Aboriginal health inequities due to the high degreeof emotional distress related to PTSD and associatedincreases in alcohol use. A high degree of other emo-tional health issues, such as anxiety, depression, andsubstance abuse co-exists with PTSD.29 Among indi-viduals with PTSD who seek treatment, up to 80 percent have at least one additional mental health diagno-sis including affective disorders (26 to 65 per cent),alcohol and drug abuse (60 to 80 per cent), or anxietydisorders (30 to 60 per cent),30 all of which have beencited as contemporary social and emotional problemsin many Aboriginal communities. Self-medication iscommon among people who experience PTSD. Peo-ple use alcohol or drugs to reduce symptoms, there-fore, alcohol and drug dependency treatment is often apart of PTSD therapy.31
Fourthly, the PTSD explanatory model is associ-ated with increased risks of physical health problemsincluding heart disease, stomach problems, abnormal-ities in thyroid and other hormonal functions, in-creased infections and immunological disorders,chronic pain syndromes,32 and other forms of ill-ness.33 In their recent book on PTSD, Edna Foa et al.state that “trauma survivors report more medicalsymptoms, use more medical services, [and] havemore medical illnesses detected during a physicalexam.”34 The correlation between Aboriginal healthconditions and the health conditions associated with
Healing the Generations
Journal of Aboriginal Health • March 2005 17
post-traumatic stress provides considerable weight tothe theory proposed in this paper that post-traumaticstress may be a major determinant of health withinAboriginal communities and a significant contributorto the current inequities between the health status ofAboriginal and non-Aboriginal populations.
COPING RESPONSE VERSUSDISORDER
Having identified a strong rationale for investigat-ing PTSD as a conceptual and clinical model for un-derstanding current health inequities, the authors re-ject the term “disorder.” Given the stigma attached topsychiatry and the negativity and implied weaknessand or illness of the term “disorder,” the authors pro-pose an alternate term while drawing on the clinicalevidence of the DSM. The authors suggest the termpost-traumatic stress response (PTSR). PTSR moreaccurately reflects the diagnostic criteria of the diag-nosis and is a more respectful term for use with bothindividuals and communities. PTSR moves beyondthe negative association with blaming the person andprovides a compassionate lens from which to betterunderstand a realistic human response to traumarooted in oppression and cultural domination. ThePTSR model serves as a place to begin to discuss thefactors contributing to the health inequalities enduredby indigenous peoples worldwide.
The authors suggest that a PTSR model for under-standing and addressing various forms of trauma in-cluding cultural degeneration and loss is a critical as-pect of healing that will acknowledge historicaltrauma and promote healing within holistic programsculturally appropriate to the individuals and nationsfor which they are designed. The authors present fivecomponents of a PTSR model for addressing Aborigi-nal health inequities. They are:1. an acknowledgment of a socio/historical context;2. a reframing of stress responses;3. a focus on holistic health and cultural renewal;4. a proven psycho-educational and therapeutic ap-
proach; and5. a communal and cultural model of grieving and
healing.
1. Social/Historical Context
PTSR within Aboriginal communities may arisefrom a multitude of individual and communitytrauma, within and across generations. This com-pound trauma is referred to as historical trauma that isrooted in cultural loss. The Royal Commission on
Aboriginal Peoples provides important documentationof the experiences of Aboriginal Peoples’ in Canada.It makes a direct link between trauma and physicalhealth. In the last 10 years, there have also been posi-tive developments that have broken the silence sur-rounding residential schools.
Partnering and sharing information about the so-cial/historical impacts on the health of indigenouspeople and conducting research between similar pop-ulations such as Aborigines in Australia, Maori inNew Zealand, and First Nations and Native Ameri-cans in North America can serve to further enable so-ciety to understand some of the complex issues in-volved in providing more effective heath care. Solidpartnerships with clear and concise goals in commoncan help further identify the relationship between his-torical trauma, health inequities, and strategies to im-prove health outcomes within and across indigenouscommunities in Canada and abroad.
2. Reframing Stress Responses
The PTSR model reframes PTSD symptoms ashuman responses to extreme circumstances. The dis-order is clearly identified as a response to an exter-nal trauma that is outside the range of tolerable hu-man experiences. The PTSR model promotescompassion for individuals and communities whohave endured external trauma that is so profoundthat it affects their ability to cope. A process of nam-ing historical and systemic sources of personal andsocial ills (imbalances) provides a critical, compas-sionate, and political lens from which to view cur-rent health inequities. As health care providers be-come more aware of the social/historical origins ofdistress, the more compassionate and therefore themore effective they can be in the delivery of healthservices to Aboriginal communities. As communitiesname historical stressors, stress responses can alsobe renamed and increasingly managed and trans-formed to health promoting behaviours and positivehealth outcomes.
3. Focus on Holistic Health and CultureRenewal
Most health initiatives, research, and services aredesigned to deal with specific aspects of health.There are mental health centres and health clinics.The mind and body dualism of the western medicalmodel continues to be maintained within the main-stream health care system. For example, independentresearch and services are funded for heart health, di-abetes, and cancer care despite the existence of com-
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18 Journal of Aboriginal Health • March 2005
mon risk factors. A PTSR model views mental healthand physical health as inseparable. The PTSR modellooks at life experiences and environmental stressorsas preconditions for health and illness. It promotes aholistic perspective on health that is consistent withcultural concepts of the Medicine Wheel with its fo-cus on the interaction and balancing of the mind,emotions, spirit, and body. Post-traumatic stress ischaracterized by intense and constant effects on themind, body, emotions, and spirit. Mainstream ther-apy for PTSD has responded to the need for respect-ful approaches to healing that incorporate a lifespanapproach to healing, focus on capacity building, andaddress all aspects of the person’s response. This in-cludes behavioural responses that need addictionscounselling as part of, or in addition to, PTSD coun-selling programs. A PTSR model would acknowl-edge historical stressors and the importance of cul-ture, Elders, community processes, and traditionalhealing.
People can and do recover from post-traumaticstress and heal the mental, physical, emotional, andspiritual wounds. Great attention has been given to theclinical and therapeutic aspects of responding to post-traumatic stress, in particular since the Vietnam andGulf wars and since the 1980s when society began tobreak the silence on child sexual abuse. There are ef-fective psycho-educational and therapeutic ap-proaches to addressing trauma that can be adapted toAboriginal settings and approaches to historicaltrauma that have been proven effective among theLakota First Nation. In particular, there are four mainaspects to healing from trauma. These include attend-ing to:i. the mind by remembering, speaking, and coming to
terms with the horrifying, overwhelming experi-ence(s) that led to the trauma response;
ii. the body by learning to acknowledge and masterthe physical stress responses like anxiety and sleep-lessness;
iii.the emotions by re-establishing relationships andsecure social connections; and
iv. the spirit by recognizing that the spiritual and thecultural have often been critical aspects of the orig-inal wound or trauma for Aboriginal people.This aspect of trauma work can be seen in the Qul
Aun Healing Initiative that promotes well-being andpride in Aboriginal identity through the use of tradi-tional cultural approaches to treatment.35
5. Communal and Cultural Models ofGrieving and Healing
The therapeutic approaches to PTSD are consistentwith Aboriginal values of respect, care, and collectivemodels of healing. PTSD healing programs are oftenconducted in communities reflecting the recognitionof a common human response to stress. Most PTSDtherapy is done with both individual and group pro-gramming. There is great benefit in bringing peopletogether who share a history of trauma. They canidentify with one another and further accept theirstress responses and support a path to wellness.
There are rich traditions of healing and purifica-tion practices in Aboriginal cultures that can be usedto help people grieve, to share their experiences ofcommon trauma reactions, and to reduce traumathrough increased understanding and cultural re-newal.36 Cultural ceremonies provide individuals,families, and communities structures within which toacknowledge and mourn common wounds. Grouphealing, within ceremonies, reduces isolation; allevi-ates guilt, shame, and anger; and enhances feelings ofself worth.
The Condolence Ceremony of the Haudenosaunee(Iroquois) is a perfect example of a cultural processwherein part of the group (the non-mourners) act ascaretakers to those who are mourning—wiping theireyes so they can see more clearly; cleaning their earsso they may again be able to hear the truth; and clear-ing their throat so they may once again breathe, speak,and eat in a healthy manner.
MOVING FORWARD: HEALING THE GENERATIONS
Mainstream health interventions directed towardsAboriginal populations are often developed outside ofa historical, cultural framework. Health programs aremost often disease-specific, focussing primarily onthe physical aspect of an individual rather than theemotional, cultural, mental, and spiritual (holistic) as-pects of health. Little or no attention is given to per-sonal and collective histories and related trauma.However, prior experiences in attempting to eliminatehealth inequities have indicated the importance ofcombining traditional Aboriginal healing methodswithin a critical historical perspective, along withavailable western medical resources.37 The report ofthe Royal Commission on Aboriginal Peoples38 em-phasized the importance of Aboriginal perspectives onhealth. It includes a belief in, and understanding of,the complex relationships between body, mind, emo-
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Journal of Aboriginal Health • March 2005 19
tions, and spirit and the importance of knowing andnaming Aboriginal histories and experience.
Various programs have been designed specificallyto address historical trauma such as the AboriginalHealing Foundation (AHF)–an important Canadianinitiative that addresses the impact of residentialschools. The AHF vision statement focuses on well-being achieved by addressing personal and intergener-ational trauma, ending cycles of abuse, and buildingstrength and resiliency in survivors of residentialschooling. The AHF programming has identified fourphases to community healing: The Journey Begins,Gathering Momentum, Hitting the Wall, and FromHealing to Transformation.39 (See Table 1.) Thesefour phase describe a developmental process charac-terized by moving from crisis to transformation.
These developmental phases are applicable to awider range of historical and contemporary health andsocial concerns. The four main elements of commu-nity healing that are identified are: leadership, psy-cho-educational programming, capacity building, andsystemic healing. These active phases can shift com-munities from supporting problem-focussed program-ming to sustainable health promoting programs andcommunities grounded in awareness of history andculture.
The Takini Network in the United States has devel-oped expertise relevant to phases two and three ofcommunity healing. They conduct research and pro-vide community education and healing to address his-torical trauma among American Indians.40 The TakiniNetwork’s psycho-educational model for addressinghistorical trauma is organized around three majorthemes: trauma testimony, trauma response issues,and moving beyond trauma. The Takini Network’sprograms focus on education about the historicaltrauma and its impact, discussing the past in a sup-portive group context, providing emotional releasethrough collective mourning/healing on both individ-ual and community levels, and reconnecting with tra-ditional cultural values. The Takini Network foundtremendous success and benefit in their programming.All of the participants found the intervention helpedthem with their grief resolution and felt better aboutthemselves after the intervention. Nearly all (97 percent) felt they could make a constructive commitmentto the memory of their ancestors. In a related study,41
the participants also experienced improvement in theirparenting. Participants in the group interventions ofthe Takini Network report beginning to understandwhy they have been feeling so bad and why they havebeen experiencing so many health and social prob-
lems. With this understanding, their pain is trans-formed into a powerful, life-giving force. These find-ings illustrate the benefits of including psycho-educa-tional and critical adult education components inhealing programs where individuals and groups givemeaning to their experience and are empowered toheal and move beyond their pain though knowledge,support, and culture.
The work of the AHF and the Takini Network illus-trate critical elements of community development andhealing programs that can inform Aboriginal healthprogramming to deal with historical stressors as ashared legacy and which draw upon culture as a com-mon key to wellness and the elimination of health in-equities.
OPPORTUNITIES AND KEY SECTORSWithin Canada, Aboriginal structures have been de-
veloped that could provide and support leadership forpartnership development, research, healing, andknowledge sharing in response to PTSR. The creationof the National Aboriginal Health Organization(NAHO) and the Journal of Aboriginal Health; the In-stitute of Aboriginal Peoples Health; the AHF; and theagreement between Canada, New Zealand, and Aus-tralia are important developments in Aboriginalhealth. Each promotes access to information, capacitybuilding, and self-determination in health with atten-tion to traditional knowledge, success stories, healthdeterminants, and Aboriginal cultures. These are im-portant vehicles for examining the intersection of thepast and the present, for addressing the impact of cul-
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20 Journal of Aboriginal Health • March 2005
Table 1: Four Phases to Community Healing
Phase 11: TThe JJourney BBegins
Gathering of a core group of people begin toaddress their own healing needs
Phase 22: GGathering MMomentum
Increasing in healing activity with recognition of rootcauses of addiction and abuse though community-wide awareness workshops
Phase 33: HHitting tthe WWall
Building healing capacity by providing training andemployment with a focus on communitydevelopment
Phase 44: FFrom HHealing tto TTransformation
Shifting from fixing problems to transformingsystems
tural loss and intergenerational trauma, and improvingthe health status of indigenous peoples in Canada andelsewhere.
Holistic, collaborative health support systems havebeen identified as important as well as governmentsthat are prepared to address “the racism that remains abarrier to progress in (the) health of indigenous peo-ple(s).”42 Post-traumatic stress is a compassionate anduseful lens to consider the gross health inequities en-dured by indigenous peoples within Canada andaround the world. The AHF examples are important tothe health of Aboriginal individuals, families, commu-nities, and nations. The authors believe the mandateand funding frame of the AHF, or a parallel organiza-tion, should be broadened to expand beyond residen-tial schooling to larger issues of cultural loss and his-torical and intergenerational trauma. FurtherAboriginal research and programming in the area ofhistorical trauma that attends to the specific links be-tween trauma and physical health is required to ad-dress health inequalities.
More education for all levels of health careproviders, researchers, policy-makers, and practition-ers is required for the impact of cultural loss and his-torical trauma to be understood, recognized, and re-sponded to appropriately. Those who work in any ofthese fields should understand the principles of PTSRassessment and treatment, be informed about tradi-tional and cultural approaches to trauma, and beaware of the potential links between trauma andhealth status. The authors support emerging healthdiscussions in which historical and intergenerationaltrauma are viewed as contributing factors to existinghealth inequalities and not only as contributors tomental health and social problems. These would beaddressed across all sectors: research, health, educa-tion, and community.• Further research, policy development, communica-
tions, and programming needs to be done by aconsortium of Aboriginal organizations to under-stand and attend to both the historical and contem-porary reasons for health inequalities with atten-tion to links between cultural loss and historicaltrauma.
• Culturally-sensitive delivery of health models thatshift the health discussions from a dualistic (mindand body) to a holistic framework are needed.Post-traumatic stress should be a routine clinicalquestion in diagnosis and assessment supported byappropriate clinical training in all of the healthprofessions. Health services should support psy-cho-educational programming and offer culturally-
appropriate and effective trauma recovery pro-gramming.
• Educators, on-reserve and off-reserve, at all levelsfrom primary to post-secondary schools, should en-sure that Aboriginal and non-Aboriginal studentsunderstand the impact of history and current social-political-economic relations on Aboriginal peopleand their health.
• Communities can engage in community develop-ment initiatives that reflect the four phases of theAHF model to promote wellness and adapt theTakini Network’s proven psycho-educational pro-gramming in historical trauma to their individualcommunity and culture.
CONCLUSIONKnowledge about the health status of Aboriginal
Peoples has largely been individualized and has beentaken out of its historical and political context. In re-sistance and opposition to this stance, the authorshave argued that the gross health inequalities be-tween Aboriginal and non-Aboriginal people must bemade a political issue. The current health status of theworld’s indigenous population is undoubtedly tosome degree a result of injuries of colonialism andcultural loss characterized by systemic attempts atdomination and cultural genocide. Future health pol-icy and programs must address current structural in-adequacies (including inequalities in environmentalrisk, inadequate housing, and lack of access to appro-priate health services and information, etc.) in tryingto address the inequalities between the health statusof the Aboriginal and non-Aboriginal populations.However, as recent statistical data indicate, health in-equities cannot be simply explained by socio-eco-nomic status or health behaviours. PTSR is a usefulmodel for understanding and addressing health inequities as it:1. provides a social/historical context for what has
been incorrectly viewed as individual/culturalweaknesses, or illness;
2. confirms a holistic understanding of well-being andcultural renewal;
3. compassionately validates stress responses as ap-propriate human reaction to trauma;
4. offers access to proven psycho-educational andtherapeutic approaches for addressing trauma; and
5. points to the use of group/community models forcollective mourning, support, and healing.PTSR is presented as a critical and compassionate
lens from which to assess and respond to the healthneeds of Aboriginal people, families, and communi-
Healing the Generations
Journal of Aboriginal Health • March 2005 21
ties within an historical, contemporary, and holisticperspective that extends beyond mental health to im-plicate a broad range of health disparities worldwide.
ACKNOWLEDGEMENTSThe authors wish to thank the anonymous peer re-
viewers and Guest Editor Kim Scott for their exten-sive editorial suggestions. Thanks to Valorie Whetungand Carmen Jones for reviewing an earlier version ofthis article from Aboriginal perspectives and to KaraGriffin for reviewing the paper from a communitypsychology perspective. Thanks also to Pamela Jamesand Yan Gu for assistance with the preparation of thereferences.
ENDNOTES1. E. Duran et al., “Healing the American Indian Soul Wound,”
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4. T.K. Young, “Review of Research on Aboriginal Populationsin Canada: Relevance to Their Health Needs,” British Med-ical Journal (Aug. 23, 2003) p. 419-422.
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Edited by Anthony J. Marsella, Matthew J.Friedman, Ellen T. Gerrity, and RaymondScurfieldAmerican Psychological Association, 1996ISBN 1-55798-908-7576 pages
In recent years, the concept of post-traumaticstress disorder (PTSD) has captured the attention andconcern of clinicians and scientists. Reactions totraumatic stress have been extensively studied. Butare such reactions universal? Although the PTSD di-agnosis is now used internationally, it is by no meansclear whether it is meaningful across cultures andethnic groups. Most of the research and clinical expe-rience validating the diagnosis has been carried out inwestern industrialized nations. Some clinicians haveraised the question of ethnocentric bias in its formu-lation.
This richly documented, edited volume is the firstsystematic examination of ethnocultural aspects ofPTSD. Leaders in PTSD research and practice exploreuniversal and culture-specific reactions to trauma.They discuss implications for research, treatment, andprevention. The multidisciplinary perspective of Eth-nocultural Aspects of Posttraumatic Stress Disorder:Issues, Research and Clinical Applications will appealto a broad audience of psychologists, psychiatrists,anthropologists, epidemiologists, sociologists, and so-cial workers.
Copyright 1996 by the American Psychological Asso-ciation. Reproduced with permission.
Peer review is an organized method of having expertsevaluate research papers for possible publication. Eachpaper in the Journal of Aboriginal Health is reviewed bya community member peer reviewer and an academicpeer reviewer, as well as the Guest Editor, to ensurecommunity relevance and academic excellence.
Peer reviewers are chosen from a list of potentialreviewers based on their area of expertise.
To prevent bias, the Journal of Aboriginal Health uses adouble-blind peer review process that ensures the peerreviewers do not know the identity of the author and theauthor does not know who completed the peer review.
After accepting to peer review an article by a specificdeadline, the reviewer will thoroughly read a submissionand fill out a simple form to recommend improvementsfor the author to make. The form covers the:
• Strengths and weaknesses of the paper• Soundness of argument• Correctness of procedures• Accuracy of facts• Relevance to the journal and the theme• Coherence• Readability• Accessibility of language
The peer reviewer then recommends that the paper bepublished as is, published with modifications, or notpublished. Positive and negative comments are importantand appropriate, but should be delivered in a way thathelps the author improve the quality of the article, notcriticizes the author.
To be added to the list of potential peer reviewers for theJournal of Aboriginal Health, please contact the NationalAboriginal Health Organization.
