Healing Indigenous Historical Trauma: Perspectives of Resilience, Resistance, and Decolonization of Treatment

Arella Skye Trustman

May 2021

A thesis in the Department of Psychology submitted to the faculty of the Graduate School of Arts & Science in partial fulfillment of the requirements for the degree of Master of Arts at New York University

Sponsor: Melissa Walls Ph.D.

Reader: Robert Ausch Ph.D.

     Historical Trauma theory (HT) was created to explain the psychological and social impact of collective traumas on the Indigenous population and the intergenerational transmission of resultant adverse health effects. That being said, not all Indigenous people suffer from these adverse health effects and there is significant variation in how people experience HT as a whole. Psychological literature on HT seldom looks at the ways in which individuals, families, and communities are protected from the negative effects of HT. In the early stages of this review, the social climate and conflict of the United States was drawing attention to themes of resilience and resistance among oppressed and subjugated minorities of this country. Furthermore, the discussions around systemic racism were highlighting the oppressive colonial ambitions that the country was founded upon, and which are very much still present. Within the literature on HT, decolonization is mentioned as a method and means to end systemic health inequities. In line with these societal discussions, this literature review will present a novel discussion on alternative and empowering responses to HT grounded in themes of resilience, resistance, and decolonization to propose advancement of HT theory and mental health treatment for Indigenous people. These alternative perspectives include consideration for the centuries of colonial oppression, meaning and cultural significance of mental health disorders, how to align and incorporate Indigenous cultural values and beliefs into theory and practice, and how to make a more equitable mental health field to address the needs of this population.

     I began looking at Indigenous Historical Trauma (HT) in the Fall of 2016 after participating in front-lines protests of #NoDAPL in Standing Rock, ND. As an Indigenous woman, I have always been subtly aware of the presence of HT within my own family system, though I didn’t have a word for it back then. I went to Standing Rock and stood with Native people from across the country in solidarity to protect the land and water. Ultimately, we stood in protest against the settler colonialism that has caused such loss for Indigenous cultures and that has threatened our very existence. The national movement around #NoDAPL, and my participation on the front-lines, resonated in a profound way within me which led me to discovering the research on HT. This past year, the power of such unified resistance was once again at the forefront of our society following the death of George Floyd, spurring massive ongoing protests against systemic racism and oppression. Taglines such as “Indigenous Sovereignty Stands With Black Lives Matter” circulated within national and social media spheres. This time has also been marked by another Indigenous rights and pipeline protest called Stop Line 3. Due to the ongoing discussions on systemic racism and oppression at the national level, and my personal experiences, I felt moved to examine the powerful effects of resistance. Resistance was not a topic I had previously come across in the literature of HT, and as such it was a perfect starting theme for my thesis topic. In thinking on resistance movements, and the courage it takes to for subjugated peoples to speak out against injustices, I reflected on how my people, Indigenous people, have persevered through the many centuries of cultural destruction and genocide. In my reflections, I came around to the theme of resilience. Resilience is the “why” and “how” behind our survival and our ability to continue to fight for sovereignty and self-determination. Decolonization of psychological research and treatment as a third theme emerged as a perfect complement to the other two themes. Decolonization is a process that involves both resilience and resistance, and in and of itself, is an act of both. It felt fitting to produce this novel literature review thesis at this time in history, and continue the work of the many incredible and resilient researchers who came before me.

     Beginning in the fourth grade, U.S students are exposed to a history of the Indigenous people of the Americas that privileges settler colonial perspectives. These narratives of settler colonialism present Indigenous people as historical relics, which position them as invisible minorities in society's consciousness. These historical narratives also gloss over settler colonialism's true nature, that resulted in the mass genocide of Indigenous people perpetrated by the federal government. Instead, these narratives present an “American Pride” perspective based upon White rights to land and resources as the country's colonizers. Colonization remains active in deeply rooted systemic practices and has resulted in health inequities that continue to affect Indigenous communities today. In the past few decades, a growing body of research has emerged which focuses on the effects of colonization as it pertains to the mental health and well-being of Indigenous people. The general term for this phenomenon is Historical Trauma (HT). This literature review will provide a comprehensive overview of the colonization of Indigenous people, the development of Historical Trauma theory, and present a strengths-based argument of resilience and resistance that has allowed Indigenous people to persevere the colonial mission of extermination and retain cultural identity, values, knowledge, and tradition. This argument will be used to advocate for the decolonization and improvement of psychological research and mental health treatment. For this paper, Indigenous/Indigenous people will refer to those who are Native to the lands of the United States. In many publications, the terms American Indian and Native American are used to describe the Indigenous people of this country, but those terms are colonized iterations of the people Native to this land, and perpetuate the settler colonialism experienced by these communities. Where applicable, Indigenous people will be identified by the nation they originate from, such as Paiute, Lakota, Diné, etc. Studies that refer to a specific group identity of Indigenous people, such as “Alaska Native,” will be presented in quotations as demonstrated.

     Articles for this review were selected using an exhaustive search method specifically looking at HT x Resilience, HT x Resistance, and HT x Decolonization. The search process was as follows:

• Several databases for psychological research and literature were identified from the NYU Library network.

• Preliminary broad searches using target keywords were conducted to see if the databases were returning relevant materials.

  • These searches used various combinations of general terms that would appear in the relevant literature such as “American Indian” AND “Historical Trauma” AND “Resilience.”

  • A good search was judged on the presence of relevant keywords in the title or abstract of papers, as well as the presence of prominent HT authors such as Brave Heart, Gone, Hartmann, Whitbeck, etc. within the first two pages of results.

  • The preliminary searches also pointed to relevant secondary keywords such as “survivance,” “protective factor,” “indigeneity,” used in possible relevant papers.  These terms were written down and used later in the exhaustive page by page searches.

• From these preliminary searches,  the following databases returned good results and were selected for the final literature review: PsychNET, PubMed, SagePub, Taylor and Francis, and JSTOR.  The databases PEP and JPSP were excluded due to lack of relevant articles returned in searches.

• Using the aforementioned databases exhaustive searches were conducted using a list of primary keywords and secondary limiting keywords and modifiers.

  • Primary keywords: “American Indian” OR “Native American” OR “Indigenous,” AND “Historical Trauma.”

    • These were terms that had to appear distinctly within any field of an article to be selected for review.

  • Secondary limiting keywords and modifiers: AND/OR “Resilience” AND/OR “Resistance” AND/OR “Risk Factors” AND/OR “Colonialism” AND/OR “Anticolonialism” AND/OR “Survivance” AND/OR “Decolonization.”

    • Other keywords selected during the preliminary search phase such as “Indigeneity,” “DAPL,” Standing Rock,” “Post-Colonial Discourse,” among others were excluded at this time. These keywords were too limiting or returned articles on topics that were not relevant to the three target themes, thus occluding more relevant materials from being selected.

After reviewing the literature, an additional two articles by Eduardo Duran and colleagues on the “soul wound” were located and included because it directly informed the creation of HT theory. The inclusion of these articles was necessary for mapping the early history of HT theory. Since published literature on HT and the target themes was limited, three recently published books were read, evaluated for content, and included in this review's discourse.  These books largely filled in gaps in research for the discussion on HT and resistance.  There are very few psychological studies that look at HT and resistance alone. In many cases, resistance themes were alluded to within studies on resilience but not distinctly examined.  As such, external print sources were the primary sources of information for those sections.  Additional information was collected from presentations given in January 2021 during the Johns Hopkins Center for American Indian Health Winter institute seminar “Mental Health Care and Delivery in American Indian Communities.” This week-long seminar was led by top researchers in the field of Indigenous mental health.  Encyclopedic online resources were also included for validation of historical content.  The research from articles, books, online resources, and presentations was synthesized into the following literature review.

     Beginning with the first contact of the European explorers over 500 years ago, the history of Indigenous people has been marked by insurmountable traumas often carried out by the government to colonize this land.  Indigenous people have endured war, disease, massacre, displacement, forced migration, and cultural destruction.  The United States government has effectively committed one of the most systematic and successful ventures of ethnic cleansing, otherwise known as genocide, in the history of our world (Whitbeck et al., 2004; Lucero, 2011; Kirmayer et al., 2014; Cromer et al., 2017).  There are 574 federally recognized tribes, 66 state recognized tribes, and hundreds more that do not fall under either jurisdiction (Burnett & Figley, 2016; Indian Affairs, 2021). Each tribe has unique traumas specific to their colonization experience, but there are some specific actions taken by the government mentioned across the literature that broadly define Indigenous colonization in the United States.  While colonial efforts were made after the settlers' arrival, colonization truly began after establishing the United States government and the need for westward expansion to accommodate the settler population.  The government touted “Manifest Destiny” and “the Doctrine of Discovery” with the accompanying ideology, which permitted European settlers to eliminate anybody that held a worldview other than Christianity and who did not readily surrender their lands.  This ideology permeated the United States from the 18th century until the early 20th century resulting in the mass destruction of more than half of the Indigenous population (BraveHeart & Debruyn, 1998; Whitbeck et al., 2004; Brayboy, 2006; Hill & Barlow, 2021).  During this period, the U.S government also entered into treaties with Indigenous tribes in exchange for their land rights. These treaties were attempts at legal negotiations for land and sometimes resulted in the establishment of reservations.  Frequently these treaties were not honored by the government, leading to fights between Indigenous tribes and settlers over land rights. The treaty period of Indigenous history lasted from 1778-1871.  When treaties proved unsuccessful for the removal of Indigenous people from Native lands, further action was taken.  Increasing conflict between Indigenous tribes and the expanding American settlements, post-American Revolution, spurred Andrew Jackson’s “Indian Removal Act” of 1830.  The removal policy would relocate Indigenous peoples to "reserved lands" west of the Mississippi in exchange for their land within exiting states (Campbell, 2003; Lucero, 2011). Between 1828 and 1838, more than 80,000 Indigenous people were removed from their ancestral lands and relocated.  This initial mass removal resulted in substantial population losses and the weakening of tribal governments (Campbell, 2003).  Within 20 years, the United States' rapid expansion resulted in the need for more land to be acquired by the U.S. government.

     The Indigenous peoples, of what is now called the United States, were termed the “Indian problem” by the U.S government, and in 1851 another series of policies were enacted by the Department of the Interior as a solution to the “problem.”  As proclaimed by the Commissioner of Indian Affairs Luke Lea, the goal of these policies was to concentrate, domesticate, and incorporate Indigenous peoples.  The most notable policy of this era was the Indian Appropriation Act of 1851, which gave Congress the power to establish reservations.  This was accomplished by designating Indigenous people as individual “wards” of the government, which meant that they no longer had any rights as a tribe and could be moved at the government's will to create more land for White settlers.  Additionally, this act invalidated all lawful treaties made between the government and tribes prior, giving Congress the ability to take established reservation lands (Encyclopedia Staff, 2020).  Using new treaties, coercion, and military force, the U.S government accelerated the removal of Indigenous people from their land and relocated them to new reservations (Campbell, 2003).  Forced reservation life contributed heavily to the demoralization of the tribes. Leaving the reservation was illegal, and the residents were dependent on the government for food, shelter, and other basic needs of survival.  Traditional means of existence were eradicated, and Indigenous people were forced to take up new means, such as farming—a task that was nearly impossible due to the poor quality of land they were given to live upon (Whitbeck et al., 2004).  Practicing traditional religion was also deemed illegal. While the U.S government claims that reservations were created to solve ongoing conflicts between Indigenous peoples and the new settlers, reservations were also a tactic to force assimilation, such as adopting the language, customs, and religious ideals of the U.S government. 

     Forced assimilation on the reservations, which includes the westernized reservation day schools, did not work as effectively or as quickly as the government wished, which led to the boarding school era of colonization (Campbell, 2003; Whitbeck et al., 2004; Garrett et al., 2013; Nutton & Fast, 2015; Enoch & Albaugh, 2016). In 1849, the Bureau of Indian Affairs, a branch within the Department of the Interior’s “Civilization Division,” began educating Indigenous children (Brave Heart & Debruyn, 1998). This education system was designed to assimilate young Indigenous children into Western colonial society.  The U.S government believed that boarding schools would further solve the “Indian problem.”  Initially, the boarding schools were meant to be voluntary, later attendance was enforced through threat and “legally” removing children from their families (Lucero, 2011). In 1879, Richard Henry Pratt established the first off-reservation boarding school in Carlisle, Pennsylvania, named the Carlisle Indian Industrial School.  Pratt’s motto was “kill the Indian, save the man.”  He devised to do this through strict military-style education and forced assimilation into the western culture by removing Indigenous children from their families and tribal environment. Pratt’s motto and policies at Carlisle Indian Industrial School became the framework for future boarding schools.  There were over 200 boarding schools established, 27 of which were off-reservation boarding schools, established in the nineteenth and twentieth centuries (Enoch & Albaugh, 2016).

     An estimated 14,000 Indigenous children were forcibly sent to these schools (Cromer et al., 2017). Boarding school was an incredibly traumatic experience for Indigenous children.  Students were documented to be as young as five years old. Since birth records were not adequately kept on reservations, children were simply taken if they looked “old enough,” so this age minimum is contested by Indigenous community members. The first step in the forced assimilation process was the removal of all signs of tribal identity.  Boys’ hair, which was a source of cultural pride, was cut short to assimilate to the American idea of what a civilized man should resemble.  Traditional clothing was taken away, and military-style uniforms were given to all students. New English names were chosen for the children, and they were forced to abandon their native language and customs.  They were expected to learn English and adopt the Christian religion.  The government took a firm stance against Native languages because they thought they were inferior.  In 1885, the government adopted an English-only policy, where all instruction and communication at the boarding schools was required to be in English.  The consequence of this was extreme isolation between schoolmates until they had acquired enough language to communicate.  For many, shame developed around the use of their native language, which led them to avoid using it.  For others, their time at boarding school resulted in forgetting their native language entirely (Haag, 2007; Cromer et al., 2017). Engagement in traditional language or customs while at boarding school resulted in punishment in the form of mental, physical, and sexual abuse (Brave Heart & DeBruyn, 1998; Haag, 2007; Wexler, 2013; Carlisle Indian School Project, 2020).  Children at the boarding schools also experienced deplorable living conditions and neglect. The extent of the abusive experience at boarding schools is not entirely understood.  The recent discovery of 31 undocumented mass graves on boarding school grounds further indicates that these schools' trauma is much more extensive than what we have documented (Cromer et al., 2017).  The many hundreds of years of colonial efforts taken against the Indigenous people of this country are best described as genocide. The U.S government refuses to acknowledge it as such.  This cultural and physical genocide experienced by Indigenous people has resulted in prolonged-lasting trauma that has passed intergenerationally and continues to accumulate through ongoing colonial ideologies that favor white Euro-Western people to this day.

“Indigenous elimination, in all of its orientations, is the organizing principle of settler society. Unlike the European Holocaust, which had a beginning and an end, and targeted humans alone, Indigenous elimination, as a practice and formal policy, continues today, entailing the wholesale destruction of nonhuman relations.” (Estes, 2019, p. 89-90)  

     Colonialism as a historical movement emerged from assertions by the popes of Europe that justified conquest, enslavement, and seizure of all lands of non-Christians, globally.  Implicitly tied to these assertions are beliefs that certain peoples, predominantly those who were not as technologically advanced, are less than human and culturally inferior to Europeans, which justified removing, oppressing, and exploiting Indigenous people and their lands (Blume, 2020).  The actual name for what occurred in the United States is settler colonialism—a specific type of colonialism where an imperial power takes native lands, eliminates Indigenous people by force, and resettles the land with a non-native population.  Settler colonialism attempts to wholly and permanently replace the Indigenous people with a settler population. This differs from other forms of colonialism in which the colonizers rule from afar and, in some cases, leave the colonized lands entirely. Settler colonialism is a process that is never complete, and the methods of colonization evolve with time.  For the Indigenous people of the United States, this evolution is best exemplified from the movement from outright extermination to making Indigenous people racial minorities dependent upon the colonizers to violating established Indigenous lands for resources (Estes, 2019).  The settler colonialism process permeates today’s society in myriad ways, such as in conflicts around sovereignty, land rights, historic relegation, which leads to further subjugation, hate, racism, stereotypes, inadequate funding, and unjust incarceration, to name a few. It has infiltrated Indigenous communities, which can be seen in the perpetuation of lateral violence that stems from the internalization of patriarchal narratives of power leading to inter-partner violence and violence between family and community members, often while under the influence (Estes, 2019; Blume, 2020).

     The term Historical Trauma (HT) only began to appear in the psychological literature a little over two decades ago. Still, it has been a concept for Indigenous people and researchers for much longer.  Eduardo Duran (1990) first introduced the concept of what is now HT under the term “soul wound.” Duran et al. (1998) note that they became aware of the “soul wound” concept around two decades prior but acknowledge that the “soul wound” has been a part of Indigenous knowledge since first contact.  Historical Trauma (HT) is defined as “the cumulative emotional and psychological wounding over one's lifetime and from generation to generation following the loss of lives, land, and vital aspects of culture” (Brave Heart & DeBruyn, 1998). It is the complete set of traumatic events a community of people experiences over generations.  It encompasses the psychological and social responses, which can be viewed in its entirety as a single traumatic trajectory (Evans-Campbell, 2008). It is imperative to note that events of HT are perpetuated with purposeful intent, which is a distinct feature of the colonialization that occurred in the United States (Walters et al., 2011).  The intergenerational movement of HT functions through many pathways of transmission.  More precise psychosocial pathways of HT transmission will be addressed in the upcoming section “Historical Trauma Response, Intergenerational Transmission, and Health Inequities.”

     The initial descriptions of intergenerational transmission harkens back to the term “soul wound.” Indigenous spirituality universally holds the value that those who have passed on still live within us and in this physical reality.  The deep ancestral connection is part of the cultural experience of Indigenous peoples, and as such, the trauma of ancestors is a part of the individual soul’s identity.  This idea is also referred to as “blood memory,” which states that the experience of those who have gone before us is embedded in the physical and psychological being and is a collection of memories one is born with (Linklater, 2014).  Cromer et al. (2017) depart from the spiritual conceptualizations described above to present a similar transmission concept in more scientifically accepted terms.  Cromer et al. (2017) suggest that HT's intergenerational transmission occurs through collective memory and consciousness of the trauma.  Even if it is a new awareness of the past, becoming aware of the trauma can cause HT's experience to manifest consciously.  In the same vein, as one becomes more encultured within their Indigenous identity, one may begin to psychologically experience the trauma through historical consciousness at a deeper and more frequent level.  Cromer et al. (2017) empirically examined this connection between HT and enculturation.  Their findings affirmed that the more individuals identified with Indigenous culture, the more frequently they thought about and felt the effects of historical losses and vice versa.  While this finding could be misconstrued as a means of victim blaming, if we look back at the earlier conceptions of “soul wound” and “blood memory,” HT is already present within the individual regardless of their level of enculturation or acculturation.  Cromer et al.’s (2017) research is merely pointing out that self-identification is correlated with HT and can activate a stronger HT response.  To further combat the possible victim blaming narrative, acculturation can contribute to the HT experience through internalization of oppression resulting in low self-esteem, feelings of emptiness, and identity confusion (Grandbois & Sanders, 2009; Garrett et al, 2013).  Another perspective of HT transmission was presented by Hartmann and Gone (2014).  These researchers proposed what they call the Four C’s of Indigenous HT transmission: colonial injury to Indigenous people from conquest, subjugation, and dispossession;  collective experience of the colonial injury by entire Indigenous communities, as well as those with collective identities whose cultural ideals and socializations were impacted; cumulative effects of colonial injury stemming from the loss of culture, land, and continued oppression which has accumulated and accentuated extended histories of harm by the dominant settler-colonial society; and

     This body of research shows that HT has many theoretical pathways of transmission. None of these hypotheses of manifestation/transmission are superior to another, although some may be easier to empirically test.  The crux of all of these theories is that collective experience and collective identity play an important role in the manifestation and transmission of HT.  Regardless of enculturation or acculturation, HT is present within the consciousness and lived experience of the Indigenous individual.  Whether one actively feels or experiences the effects of HT does not mean that it is not present and can manifest at any time.

     Hartmann et al. (2019) present a thorough discussion on the development of HT under three domains of thought: clinical condition, life stressor, and critical discourse, all with a common basis of decolonial motivation and Indigenous empowerment.  Each domain provides a unique lens for understanding the manifestation and reinforcement of HT.  The first body of research conducted on HT explores it as a clinical condition that conceptualizes intergenerational PTSD as a set of complex colonial experiences and behavioral outcomes specific to Indigenous people (Duran, 1990; Brave Heart & DeBruyn, 1998; Hartmann et al., 2019).  Below, I explore each of these three domains in further detail.

     HT as a clinical condition describes massive cumulative trauma across generations which is not adequately captured by the limited scope of PTSD.  The specific causes of HT under this definition are outlined as loss of land, language, and culture stemming from lived experiences of relocation, subjugation, and assimilation resulting in symptoms which include depression, anxiety, somatic symptoms, self-destructive behavior, substance abuse, strong identification with ancestral pain, and fixation/rumination on contemporary and ancestral trauma to name a few (Brave Heart & DeBruyn, 1998; Hartmann et al., 2019).  The clinical condition definition was introduced to promote professional support for establishing and implementing effective culturally informed psychological interventions (Kirmayer et al., 2014; Hartmann et al., 2019).  This was accompanied by critiques of Western psychological theories and practices for Indigenous communities.  A discussion on the inadequacies of western psychological theory and treatment will appear later on in the section “Barriers to Improving Treatment for HT and Causal Mental Health Inequities.”   The pitfall of the clinical condition perspective is that it pathologizes the HT experience as an illness or disorder, which can be dangerous given the negative stigma in contemporary society towards mental illness and mental health care (Linklater, 2014; Hartmann et al., 2019).  Additionally, the clinical condition denotation is precarious as it assigns a certain degree of responsibility upon the individual for their disorder. It can very easily broach the realm of victim blaming and as such it must be approached with caution.      

     HT as a life stressor emerged from the second generation of researchers, largely from the public health field.  HT as a life stressor shifts the theory from clinical perspectives of traumatic memory and psychological injury to the stress-coping model.  HT was reinterpreted as a high degree of stress that directly affects Indigenous health at biological, psychological, and social levels.  Colonization is still included as an impactful historical event and stressor. It expanded the HT theory, bringing attention to proximal stressors in the contemporary settler-colonial environment such as discrimination, microaggressions, poverty, limited access to care, and many others (Burnett & Figley, 2016; Hartmann et al., 2019).  The “Indigenist” stress-coping model adapted by Walters and Simoni (2002) is a great framework for understanding HT as a life stressor with potential cultural buffers.  Their model proposes that the effects of life stressors, including HT, on health are buffered by cultural factors.  The cultural factors they highlight are enculturation, positive identity attitudes, spiritual coping, and traditional health practices.  The researchers suggest that these cultural factors strengthen psychological and emotional health so that the effects of stress are less impactful upon the individual. This model explicitly outlines pathways between social experiences and health outcomes with the inclusion of social, psychological, and cultural influences as determinants of health (Walters & Simoni, 2002).  Additionally, under the domain of HT as a life stressor, Whitbeck et al. (2004) created the Historical Loss and Associated Symptoms scales which were the only validated quantitative measurement of HT until McKinley et al.’s (2020a) Historical Oppression Scale.   HT as a life stressor also informed Evans-Campbell’s (2008) “multilevel framework” that explores the interaction between individual, family, and community responses to elaborate on HT's intergenerational transmission.  One major distinction of HT as a life stressor from HT as a clinical condition is that it spurred research on community prevention strategies to address Indigenous health inequities.  These strategies have largely promoted the idea of culture as a protective mediator for the impacts of HT, much like Walters and Simoni’s model (2002).  Culture as a protective medium is becoming a dominant perspective for the decolonization of the treatment framework (Hartmann et al., 2019; Walls & Whitbeck, 2012a).  The HT as a life stressor domain advances decolonization by highlighting Indigenous people's resilience for retaining protective cultural factors despite the many attempts at destruction, and at a greater level, culture as resilience for HT's potential negative health outcomes. 

     HT as a critical discourse can be viewed as a critique of the two previous modes.  HT as a critical discourse is a sociopolitical metaphor that looks at HT and Indigenous hardship in relation to the ongoing colonial oppression that maintains social, political, and economic dependence.  It acknowledges the protective factor of resistance to colonialism from surviving forced assimilation to direct actions taken against the government as a critical discourse.   As one example of critical discourse approaches to HT,  Bryan McKinley Jones Brayboy introduced a useful framework of HT as a critical discourse in 2006.  Brayboy (2006) proposed a tribal critical race theory, titled TribalCrit, to address the range and variation of experiences Indigenous people encounter and provide a theoretical lens for educators and researchers who are dissatisfied with the theories and methods available.  He outlines nine tenets of TribalCrit theory which are as follows: 1. Colonization is endemic to society, 2. U.S policies toward Indigenous people are rooted in White Supremacy, 3. Indigenous people occupy an invisible space that accounts for their identity's political and racialized nature, 4. Indigenous people have a desire to obtain tribal sovereignty, autonomy, self-determination, and self-identification, 5. Culture, knowledge, and power have new meaning when examined through an Indigenous lens, 6. Government and educational policies toward Indigenous people are linked to a goal of assimilation, 7. Tribal traditions and values are central to understanding Indigenous people's lived existences and illustrate their resilience, 8. Stories are not separate from theory, and they are real sources of information and data that make up the theory, 9. Theory and practice are connected in explicit ways, and as such, scholars are obligated to do work for social change.  Tenet 8 specifically aligns with the field of mental health research.  Western based methodological research is lauded as the only real and justifiable source of information within the scientific community.   It is predicated on positivist frameworks that state that any rational idea can be tested scientifically with Western method, thus if an idea cannot be measured or tested then it is not real.  Stories within Indigenous communities provide cultural and moral tools that have psychological implications, and as such, should be included in research with the same value as “hard” science.  Stories in and of themselves are data about Indigenous world views, and while they are immeasurable, the content can be broken down into measurable concepts; thus, stories are a basis for theories (Brayboy, 2006).  Tenet 9 is also important as it promotes activism and action within research and scholarly work.  In doing HT research, one must expose the structural inequalities and assimilation processes and produce works that deconstruct them.  TribalCrit calls for individuals to put their theories into action to change Indigenous people's situations at large.  Allowing for theory to remain abstract leads to indirect action when direct action is needed to transcend HT and all of the colonial processes that perpetuate it (Brayboy, 2006).  HT as a critical discourse directly highlights how the field of psychology and health perpetuate colonial ideologies that undermine Indigenous sovereignty, self-determination, and wellbeing, through inherently western methodologies and pathologies and strives to draw attention to and address in action the colonial oppressions and inequities (Brayboy, 2006; Hartmann et al., 2019).

     HT as a clinical condition accounts for the individual psychological dynamics of manifestation and transmission.  Under the domain, researchers identified a discrete set of symptoms that are resultant of HT.  The clinical conception also provided a basis for amending psychotherapeutic care to better attend to the specific psychological conditions of HT.  HT, as a life stressor, expanded on the ideas of the clinical condition to include external social and societal influences that reinforce and perpetuate it within individual, family, and community systems. It also opened space to examine protective factors of Indigenous identity that moderate HT experience.  From this domain, HT research shifted attention away from individual pathology and spurred research on interventions that have impact at population levels.  HT as a critical discourse supports advancement within the previous two domains by drawing attention to the embedded colonial systems that are continually contributing to the cumulative effects of HT.  It examines power dynamics within society, including research and education, that reinforce oppression and subjugation.  As a critical discourse it also advocates for Indigenous self-determination and sovereignty which is important for creating culturally appropriate and impactful health interventions.

     HT causes a range of psychological, behavioral, and social health outcomes that are interpretable using Evans-Campbell’s (2008) multilevel framework.  In this framework, HT has three distinct levels of impact: individual, familial, and community.  While each level has its own set of challenges, they are interrelated.  Individual experiences affect the family, and reciprocally family experiences will affect individuals and future generations.  Individual and familial levels are dependent on community responses, but at the same time, the individual and familial levels of trauma reinforce community responses.  This constant interaction further exemplifies how HT is passed intergenerationally (Evans-Campbell, 2008). 

     At the individual level, HT experiences include post-traumatic responses that are the immediate result of lived experiences with trauma (Cole, 2006). Such lived experiences can include relocation from Native lands to reservations, removal in mass such as the “Long Walk” of the Diné  and the “Trail of Tears” of the Cherokee, Muscogee, Seminole, Chickasaw, and Choctaw nations, the disruption of traditional living practices on reservations, forced assimilation through government policies and boarding schools, and ongoing acts oppression, discrimination, and violence within and outside of communities.  Post-traumatic responses include detachment, avoidance, intrusive thoughts, and hyper-arousal, resulting in insomnia and irritability (Evans-Campbell, 2008; Denham, 2008).  These symptoms can be varied from person to person and rely on whether the initial stressor was acute, a single event, or chronic, an event or trauma that was recurring or persistent.  As mentioned, Indigenous people have experienced a range of acute and chronic stressors.  More severe post-traumatic responses have also been linked to events that are viewed as uncontrollable or unpredictable or involve separation from family during the event (Evans-Campbell, 2008).  One potential long-lasting result of Indigenous historical traumas is extreme reactivity to stress. Such reactivity can result in poorer coping responses to stress. When combined with depression and substance misuse as comorbid conditions, the difficulty in managing stress is much more pronounced, creating an accumulation effect for mental and behavioral health (Cole, 2006).  Substance abuse is often a result of trauma, and can be self-protective.  It is a way to avoid and numb emotions and recollections of the trauma (Cole, 2006; Blume, 2020).  Those who attended boarding schools manifested many interpersonal problems in behavior and communication, depression, and alcoholism (Whitbeck et al., 2004; Cole, 2006; Burnette et al., 2019; Blume, 2020).  In addition, a deep sense of shame around one’s Indigenous identity developed (Cole, 2006; Cromer et al., 2017).   The identity shame some Indigenous people feel is a result of hundreds of years of oppression and destruction that was exacerbated by forced assimilation at boarding schools.  It manifests as self-denigration, negative self-image/ low self-esteem, and disorders such as substance abuse and dependence, depression, and suicide (Cole, 2006).  These individual issues then affect the family and future descendants. 

     As mentioned, boarding school attendance plays a significant role in HT response, health inequities, and intergenerational transmission. First, being separated from parents and siblings negatively affected individual relationships with family members and the greater community. The individual became alienated and detached due to their boarding school experiences, from loss of culture and language to the direct abuse.  Family members were also traumatized by the forced separations (Cromer, 2017).  Additionally, boarding school attendance interrupted the transmission of traditional and healthy child-rearing practices.  Children of boarding school attendees were/are more likely to experience interpersonal trauma such as childhood physical, emotional, or sexual abuse. This is due to the loss of traditional child-rearing practices and the consequence of the extensive abuse experienced at boarding schools that introduced dysfunctional behaviors such as corporal and abusive punishment as child-rearing practices (Cromer, 2017). This does not mean that all boarding school attendees had issues with abuse and violence later in their families, but it is a prominent outcome.  Studies have found that Indigenous women experience intimate partner violence at rates higher than men and women of any other race (McKinley et al., 2020b).  Burnett and Figley (2016) report that 46% of Indigenous women have experienced intimate partner violence (IPV) compared to 43.7% of non-Hispanic black women, 37.1% of Hispanic women, and 34.6% of non-Hispanic white women. Along with the high IPV rates, Indigenous children experience maltreatment at a rate that is 1.5 times higher than that of white children (McKinley et al., 2020b).  These researchers discuss that the high rates of violence seen in these groups stem from the internalization of colonial ideologies of patriarchal dominance and sexism, which can be traced to the assimilative policies and education at boarding schools.  In line with these suggestions, Freire’s (2000) discussion on oppression proposes that lateral violence emerges when the marginalized person adopts the negative beliefs and behaviors of the oppressor.  The marginalized individual, who feels powerless, lashes out at others of equal or less power i.e. woman and children.  In fact, the oppressed becoming an oppressor is a social behavior trend that is seen across all groups of people, and even in school age children with the commonly observed “bullied becoming the bully” dynamic.  Given the long oppressive history of Indigenous peoples, the higher rates of lateral violence are an unsurprising outcome of colonialism.  Beyond high rates of interpersonal violence, generations of boarding school attendees had subsequent issues with attachment and relationships, resulting in behaviors such as distancing oneself from their spouse and children, or being emotionally unable to meet their needs.  These effects were compounded by whether individuals experienced harsh parenting at home in addition to their negative experiences at boarding school.  These experiences resulted in trust issues, trouble building relationships, parenting problems, and poor communication skills.  While some attendees had positive home lives or positive boarding school experiences, the vast majority fell into the category of double negative experiences and failed to develop appropriate nurturing and discipline skills (Brave Heart et al., 2011).

     The transmission of trauma within families is greatly affected by parent exposure to trauma.  Having two traumatized parents dramatically increases the likelihood that negative effects will be carried down to children.  Parents who display chronic post-traumatic responses have children who are at significantly higher risk for developing post-traumatic responses (Evans-Campbell, 2008).  One of the most influential factors impacting the transmission of intergenerational trauma is communication around the events.  Avoidance of communication around traumatic events is significantly correlated with poor mental health for survivors' children and grandchildren.  By not communicating the experience of trauma to their children, the children are unable to comprehend the reasons for their parent’s behaviors and emotions and often will develop survivor’s guilt. This lack of communication also manifests itself as anxiety and low-self-esteem in children and grandchildren of survivors (Evans-Campbell, 2008).  Furthermore, descendants of traumatized individuals are found to have higher stress vulnerability than those who are not being affected by HT.  Thus, when descendants experience contemporary stressors, they are more likely to exhibit high reactivity to the event and increased post-traumatic response symptoms (Walters et al., 2011).  Overall, trauma is carried over generations by its impact on the individual, resulting in later familial issues, leading to maladaptive behaviors and mental health issues in their children, which then perpetrates further problems for the families of those children and future generations, cycling for decades within some families.

     HT isn’t just influential on the individual/familial level but impacts entire communities characterized by its effects.  The initial impact of trauma on the community level can include widespread depressive symptoms.  While the initial trauma response may subside over time, the community, as a whole, still suffers from the effects of the HT.  One of the significant ways HT is carried over generations is through sustained loss.  Government creation of and relocation of communities to reservations caused the loss of ancestral land, loss of lives during and after relocation, loss of traditional culture, spirituality, values, and more, leaving the community as a whole “wounded” (Walters et al., 2011).  Living within a wounded community exacerbates the trauma response.  Those living in a wounded community, carry a collective “survivor identity” with trauma responses such as anger, transposition, guilt, inability to bond, and somatic symptoms such as generalized pain seen across all members within the community.  Secondary outcomes of living in a wounded society and having a collective “survivor identity” manifest as high levels of substance abuse and violence, compounded by the individual and family experience within the community (Evans-Campbell, 2008).  Another community-wide impact of HT is that of alcoholism.  It has been theorized that Indigenous people use alcohol as a crutch for social relations.  Alcohol is a way for Indigenous people to deal with their feelings of hopelessness and depression. Alcohol use socially provides a sense of identity and belonging by allowing the person to function within and be a part of a group within their fractured community (Blume, 2020).  Alcoholism is a direct way the individual, family, and community levels interact because of historical trauma.  Furthermore, alcoholism is detrimental to individual success in greater society because it further confirms and strengthens the stereotype of the “drunken Indian.”  Stereotypes such as this, and ongoing oppression and microaggressions, continue to undermine Indigenous identity and communities.

     In summation, HT is a determinant of many Indigenous health inequities.  Directly experiencing events of HT are linked to higher levels of depression, anxiety, suicide and related behaviors, substance use, violence, interpersonal problems, and more.  Descendants of these individuals have been shown to manifest a similar set of mental and behavioral health issues as well as intergenerational survivor’s guilt.  These effects are compounded and reinforced at the community level through collective “survivor identity.”  Recalling the life stressor domain of HT, there are also contemporary societal level reinforcers of HT such as ongoing oppression, subjugation, and prejudice, that contribute to the additive and perpetuating cycle of HT. The interaction between individual, family, and community expressions of HT contribute to the intergenerational transmission of HT and related health outcomes. Since all of these health outcomes are explicitly tied to HT in this body of research, it is of interest to focus direct attention on healing HT before or alongside treatment for the variety of resultant psychological and social issues.

     Indigenous health inequities are vast and complicated after five centuries of trauma and colonial oppression. We do not have a complete picture of all the ways in which HT impacts individual, family, and community health.  Many of the available studies solely focus on the various risk factors such as repeated and traumatic losses, acculturation stress, poverty, lack of resources, among others mentioned previously, that predispose Indigenous peoples to adverse health effects (LaFrambois et al., 2006).  While HT theory provides a lens for understanding the basis of these adverse health effects, a significant drawback in the conceptualizations is the lack of attention toward protective factors that have allowed for this population to survive (Denham, 2008; Garrett et al., 2013; Burnette et al., 2019).  To move the field of research on Indigenous health forward, greater attention needs to be given to the protective factors that mitigate HT effects.  In defining such protective processes, HT as a life stressor, as discussed previously, provides the best fitting perspective for the upcoming discussion on resilience.  HT as a life stressor accounts for the many historical and contemporary impacts of colonialism as a set of distal/internalized stressors and proximal stressors that perpetuate the intergenerational passage of trauma and subsequent health inequities. Expanding upon this conceptualization of HT, there is an interaction between risk factors that trigger and exacerbate problems and protective factors that buffer adverse outcomes or promote positive results across the interaction's multilevel framework.  This interaction of factors dictates whether an individual will experience wellness after facing adversity (Burnette et al., 2019).  Uncovering the protective factors that moderate adverse HT outcomes is the focus of the following section on Indigenous resilience.

     In the articles reviewed, which specifically focused on HT and resilience, the term resilience was frequently presented without defined parameters.  Resilience can occur at the individual, family, community, nation, global, and ecosystem level (Linklater, 2014).  Resilience varies in definition depending upon the lens and level in which one studies it.  Scholarly attention to the concept of resilience has evolved from initial focus as an individual trait that constitutes the ability to adapt and respond positively to stressors and adversity to a developmental process that is inextricably tied to protective factors within the individual’s family, community, culture, and environment at large (LaFramboise et al., 2006; Wexler, 2013; Burnette & Figley, 2016; Burnette et al., 2019).  While the research on Indigenous resilience is very contemporary, it is not a new concept for Indigenous communities. HeavyRunner and Marshall (2003) note that resilience is implicit within the Indigenous worldview. Every Indigenous language has a strengths-based word that communicates ideals of not giving up, trying harder, and the presence of ancestral strength.  Within these definitions, the assertion of culture and ancestral strength as resilience ties into HT discourse, highlighting the reclamation of Indigenous identity through cultural practice as the path to overcoming HT (Duran et al., 1998).  The following section will examine studies that promote culture as the basis of resilience for protecting against adverse health outcomes rooted in the HT trajectory.

     The earliest study I was able to locate that empirically examines Indigenous cultural resilience is LaFramboise et al. (2006).  These researchers looked at possible predictors of Indigenous youth resilience as measured by pro-social versus problem behavioral outcomes. Data was collected from a survey of 212 Indigenous adolescents between the ages of 10-15 years living on or near reservations in the upper Midwest.  Measurements included self-esteem, enculturation, spiritual involvement, maternal warmth, community support, perceived discrimination, and a novel construction of child resilience.  This new measure is based off pro-social behavior, including attitudes toward school, academic plans, and current grades and problem behaviors of alcohol use, other substance use, and externalizing behavior. Findings indicated that higher ratings of maternal warmth, enculturation, and community support resulted in incremental increases in resilient outcomes.  In another empirical study, Walls and Whitbeck (2012b) collected data from Indigenous youth and their biological mothers, on eight reservations in the United States and Canada, as a part of a longitudinal study looking at culturally specific resilience and risk factors that impact child wellbeing. Their analysis provided evidence of the intergenerational transmission of problem behaviors.  In their discussion, the researchers suggested that educating community members about cultural values, spirituality, and traditional practices would disrupt HT events' cyclical effects that resulted in the cultural loss.  Extrapolating from this suggestion, the researchers are keying into the culture as a decisive factor of resilience against developing and preventing problem behaviors.  Enoch and Albaugh (2016) reviewed the empirical literature on alcohol use disorder (AUD). They found that enculturation increases resilience against developing AUD in adults, and two subcomponents of enculturation, participating in traditional activities and traditional spirituality, had positive effects on alcohol cessation.  Recalling Cromer et al.’s (2017) findings that enculturation was associated with increased HT rumination, enculturation in the present study is protective against HT.  Indigenous enculturation as both a trigger and as a protective factor is indication that these processes need greater exploration within research. This ties into the need for more empirical research on Indigenous resilience in order to conclusively defend the assertion that cultural awareness and engagement protect against HT's deleterious effects. 

     The majority of research returned from searches, that specifically focused on HT and resilience, is qualitative and utilizes culturally relevant modes of storytelling and personal narratives.  Denham (2008) analyzed resilience narratives in a multigenerational Indigenous family.  Resilience was grounded in stories and metaphors of cultural protection and ancestral strength shared within the family across generations.  These narratives provide lessons and teachings on how to overcome adversity.  Content of the narratives included remarks such as “Native people must remember the strength of their blood, the same blood that ran through your ancestor’s veins . . .” (Denham, 2008, p. 406) and recounting the use of a traditional power song, from an ancestor that was killed during colonization, to help this individual get through his war service in Vietnam.  Similarly, Grandbois and Sanders (2009) analyzed resilience narratives from eight Indigenous elders between the ages of 57-83.  Their analysis revealed five themes of resilience: resilience must be studied and understood within an Indigenous worldview context; resilience is embedded within Indigenous culture; Indigenous elder resilience comes from their connection to each other, family, relatives, and tribal communities; resilience comes from a greater connection or “oneness” that they feel with all creation; resilience comes from a legacy of ancestral survival.  Goodkind et al. (2012) conducted a similar narrative-based qualitative study with youths, parents, and grandparents from twelve Diné families.  While conceptions of trauma, survival, and resilience varied across age groups, all participants mentioned family, community and spirituality/traditional belief systems as a source of strength that allowed for their ancestors to survive, and further, for themselves to overcome current adversity. Goodkind et al. (2012) also noted frequent references to traditional healing ceremonies, seeking out a medicine man, and the use of traditional herbal remedies, as a preferred and desired form of treatment.  The desire for traditional healing methods as a basis of treatment is an important finding from this study and will be discussed further in the section of “Recommendations for the Future: Decolonization of HT Research and Treatment.”  Wexler (2013) conducted another narrative study among youths, adults, and elders who identify as “Alaska Native,” specifically Inupiaq. From the narrative analysis, the recurrent theme of culture as resilience continues to emerge.  Elders and adults spoke about how the values, knowledge, and traditional practices of their culture grounded them and provided strength to overcome adversity, as their ancestors had done before, thereby supporting the recurrent theme across existing studies of culture as a source of resilience.  The concept of culture as resilience was less apparent in the youth narratives. However, they articulated that they “felt better” after hearing Inupiaq stories, eating Native foods, and exploring their Native lands with family.  This indicates that they are experiencing the protective nature of their culture even though they have yet to conceptualize it as a strength.  Ramirez and Hammack (2014) did an interpretive analysis of two California Indigenous tribal leaders' life stories.  These leaders recounted how their tribal and Native identities, grounded in spirituality, provided a sense of meaning, purpose, and construction of personal resilience that mitigated HT's potentially harmful effects.  Furthermore, translating trauma into action, such as cultural reclamation and revitalization, for future generations' social and political benefit, highlights how across time, culture has been, remains, and will be the resilience strategy for Indigenous communities.  Building off Ramirez and Hammock’s (2014) conclusions, all of the aforementioned studies exemplify how culture makes Indigenous people resilient to HT's effects.  Loss of culture is defined as a part of HT. As such, the fact that these communities have held onto their cultural values and practices, in and of itself, speaks to the resilience embedded within cultural identity and the resilience of the culture as a whole.

     When looking at the previous studies, family connection, community connection, and cultural connection emerge as recurring dimensions of resilience worth attention in creating mental health treatments.  These dimensions align with existing theories of resilience, such as the Stress-Buffer Hypothesis which suggests that individuals with broad support networks exhibit less negative emotional arousal when faced with adversity because of the resources provided by others, and Social Control Theory which suggests that emotional attachment to social structures deters individuals from deviant behavior because of the value of their connections (Markstrom & Moilanen, 2016). Alignment with such theories speaks to the general validity of the aforementioned results.  These theories could be utilized as a framework in future empirical research on Indigenous resilience.

     As resilience is akin to the culture's power to protect individuals from adverse outcomes, resistance is akin to Indigenous people's continuous efforts to respond to and transcend HT (Burnette & Figley, 2016). Resistance, at heart, is a process to overcome oppression by creating a critical dialogue on root causes and generating social action to overcome oppressive structures that fuel inequality. Resistance is the fight for liberation and emancipation (Freire, 2000).  Freire (2000) proposed that the path to liberation for Indigenous people is to decolonize through rejecting the colonial mentality and replacing it with sovereignty, and reestablishing the “strengths” of the peoples prior to colonization. In essence, this approach centers on returning to the values, customs, and traditions of Indigenous life that are protective. Recalling Brayboy (2006), TribalCrit tenets acknowledge that colonization is woven into the fabric of society through U.S policies grounded in White Supremacy and assimilation.  TribalCrit proposes that to combat such structures direct action must be taken within education and research in ways that promote tribal sovereignty and self-determination by utilizing Indigenous viewpoints and traditional knowledge often grounded in oral stories.  In alignment with TribalCrit’s emphasis on the value of oral tradition, Vizenor (2008) created the term “survivance” to highlight Indigenous peoples' active presence and continuance stories of resistance and resilience. Vizenor (2008) argues that by adhering to the colonially imposed definition of victims or remnant survivors, Indigenous people complete, psychologically, the “the not-quite-entirely successful physical genocide” (pg. 25).  Survivance is more than just survival; it is the power that Indigenous people have demonstrated through their commitments to their culture, traditions, and native lands, despite the adversity of colonization. It reduces the power of the destroyer (colonizers) by highlighting Indigenous people's power (Vizenor, 2008).  Vizenor’s (2008) survivance through storytelling is also relevant in Denham’s (2008) analysis of Indigenous resilience.  Denham (2008) explains the narrative process, noting that although the stories and direct meaning of such stories are important, it is the manner in which the narratives are framed and conceptualized that makes them significant. Walkup’s (2021) general discussion on problematic narratives for mental health grounds these theories into ongoing psychotherapeutic treatment practice.  He asserts that the ways in which we view experience impact future mental health.  Shifting the narrative from victim to survivor to hero through dialectic rescripting allows individuals to find power and purpose within their experience. 

     Indigenous resistance and survivance specifically exemplifies this healing narrative shift and ties into Freire’s (2000) proposed path to liberation through decolonization and Brayboy’s (2006) TribalCrit emphasis on Indigenous knowledge as power.  Across the literature, Indigenous narratives, especially those about resistance, are grounded in a strengths-based perspective that emphasizes how ancestors, family, and community members have been successful at overcoming adversity and remaining strong when faced with trauma.  By emphasizing the positive lessons instead of failure, victimry, hopelessness, and other adverse outcomes, these narratives empower Indigenous people to continue their survival and fight for liberation.

     Since the arrival of the first settlers, Indigenous people of this country have actively resisted colonization.  At the most superficial level of resistance, Indigenous culture, traditions, and knowledge have persevered through the many attempts at elimination.  Although displacement to reservations disrupted traditional means of living, and many holders of knowledge passed away during removal and relocation, Indigenous people fought to keep their cultural heritage alive.  Those who remained shared a sense of moral imperative to assert their traditional culture's value across time (Vizenor, 2008).  Engaging in traditional cultural and activities of various forms was illegal on reservations until the Religious Freedom Act of 1978, but the colonizers could not silence Indigenous voices. As such, storytelling is one way that Indigenous people were able to resist colonization and retain cultural knowledge as pointed out in Brayboy (2006), Denham (2008), and Vizenor (2008). Wexler (2013) brings this process of resistance into contemporary existence through her analysis of three generations of narratives grounded in the idea of culture as strength and purpose.  Elders recalled how the teachings of their tribe, passed down from generation to generation, “linked them to family, home, and tradition, and importantly to a feeling a part of something intergenerational and therefore larger than themselves” (Wexler, 2013, p. 80) invoking the long history of resisting oppression and destruction through maintaining culture.  Adults in the study took this idea further, asserting the value of tribal culture and actively resisting colonialism.  Adults directly suggested working hard to gain back what has been lost to colonialism, indirect resistance to the colonial erasure, and paralleling the “fierce willpower”  (Wexler, 2013, p.82)  of their elders and ancestors to overcome.  Doria et al. (2020) conducted six talking circles with “American Indian and Alaska Native” elders, adults, and youths looking at suicide and suicide prevention.  From these talking circles, the necessity of preserving cultural practices was highlighted as a critical form of resistance to colonialism and vital to suicide prevention.  One participant eloquently pointed this out, stating, “because when you are living in a bigger environment that has its goal to destroy [Indigenous] identity, then it’s seen as more important to put that element in there and to fight for that” (Doria et al., 2020, p.12). Doria et al.’s (2020) study points out the inherent link between culture as a protective factor in the form of resilience and culture as the driving force of active resistance against colonialism.  Culture thus exists as a locus of healing and a locus of empowerment, and as such, resistance can be counted as another protective factor against HT. Culture as empowerment is exemplified in the following section which highlights key direct actions and activism movements grounded in Indigenous rights' reclamation.

“[she] stood up and she began to sing a prayer song in Yurok… She was holding her arms  up and singing and all of the birds in the area came and began to circle around above…  It was a very powerful moment that here’s this little woman who is so small in stature but so big in her medicine…” — Former Yurok Chair and Vice Chair Susan Masten relaying a story of her grandmother who was hanging on a net that was being pulled on by federal agents during “protest fishing” on the Klamath River in 1978 (Lara-Cooper & Lara, 2019, p.54)

     Resistance as an Indigenous tradition has been established through direct actions taken against colonization.  While there are far too many individual tribal direct actions of resistance to recount them all here, there are a few that stand out as influential collective resistance movements.  One of the most prolific early resistance events was The Ghost Dance (1889-1890).  Wovoka, a Paiute healer, had a vision that showed “the restoration of Indigenous peoples to their rightful place in a world that was taken from them” (Estes, 2019, p. 122).  In this vision, it was foretold that dead ancestors and the buffalo would once again walk the earth, that settlers would be erased, and human and non-human relationships destroyed by colonialism would return in balance (Estes, 2019).  An unnamed Lakota man who participated in the Ghost Dance as a young runaway from boarding school recounted, “The rumor got about: “The dead are to return.  The buffalo are to return.  The Dakota people will get back their way of life.  The white people will soon go away, and that will mean happier times for us once more!” That part about the dead returning was what appealed to me” (Estes, 2019, p. 123).  This quote highlights the deep desire of Indigenous people to return to their Indigenous ways of knowing and a promise of revival that sparked hope within Indigenous communities across a nation that was entrenched in the nightmare of colonization.  The Ghost Dance prophecies, prayers, and songs were transcribed and delivered around the country via trains and mail, where they were read to fellow Ghost Dancers, creating a widespread movement.  The Ghost Dance movement culminated in the execution of Sitting Bull for spreading the Ghost Dance, and then the massacre of Ghost Dance leaders and ~300 Lakota men, women and children, at Wounded Knee (Estes, 2019).  In contemporary history textbooks, the Wounded Knee massacre is always briefly mentioned, but the massacre's resistance movement is absent.  The Ghost Dance was a prolific resistance movement that invigorated Indigenous people from all corners of the nation to unify in dance, prayer, and expression of cultural identity against federal laws and colonialism at large.  If one looks at the history, this movement aligns with a sharp increase in the establishment of off-reservation boarding schools to assimilate Indigenous children. Thus, the colonizers felt the presence and the power of Indigenous people and targeted the youngest and most vulnerable among them in an effort to eradicate Indigenous people once and for all. 

     Additional notable acts of resistance came in the 1960s and 70’s with the Red Power movement.  This movement occurred in response to the House Concurrent Resolution 108, which saw the termination of sovereignty for more than 100 tribes and dissolving millions of acres of Indigenous treaty lands. The Relocation Act of 1956 resulted in an estimated 750,000 Indigenous people moving off-reservation. These government actions mark what scholars call the “termination era” because it marked the “legal” overthrowing of established Indigenous governments, stealing more treaty lands, and the final push for the extermination of Indigenous people and culture (Estes, 2019; Hill & Barlow, 2021).  The new effort to assimilate Indigenous people via urban relocation resulted in further cultural disruption and presented new challenges with unemployment, low-wage jobs, discrimination, acculturation stress, and alienation from tribal identity (LaFrambois et al., 2006).  The U.S government’s termination efforts had limited success by destabilizing Indigenous communities and further forcing assimilation, but there was an unforeseen consequence of urban relocation. Indigenous people had repeatedly demonstrated that removal from ancestral lands and tribal communities did not remove their indigeneity.  Instead, urban relocation connected Indigenous people from many different tribal affiliations resulting in the creation of pan-Indigenous resistance organizations, the most notable being the American Indian Movement (AIM).  The first publicized direct action of AIM (along with eight other resistance organizations) was the “Trail of Broken Treaties” march from the West Coast to Washington, D.C.  Thousands of protestors descended on Washington, D.C., and occupied the Bureau of Indian Affairs (BIA) building from November 3-9, 1972, demanding resolution for the grievances outlined in the “Twenty Points.”  Protestors called for the restoration of treaties and federal recognition of tribal sovereignty.  This direct action resulted in an Indigenous person's appointment to the BIA (Estes, 2019).

     In remembrance of the 1890 Wounded Knee Massacre and opposition of the federal government's “Indian Reorganization Act,” AIM and the Oglala Sioux Civil Rights Commission (OSCRC) began a 71-day occupation of Wounded Knee, SD, in February 1973. The protestors called for the expulsion of the Pine Ridge Reservation corrupt tribal chairman Dick Wilson and the restoration of treaty rights.  For 71 days, Wounded Knee became an independent Indigenous territory.  Worldwide media attention garnered support and raised awareness regarding the oppressive practices of the federal government.  The occupation of Wounded Knee culminated in violent stand-offs and the deaths of two protestors.  During these decades, the Wounded Knee occupation and other direct actions of the Red Power movement gave Indigenous people a national voice and triggered the reestablishment of Indigenous sovereignty (Estes, 2019).  The Red Power movement directly resulted in the American Indian Religious Freedom Act and the Indian Self Determination and Education Assistance Act. The Red Power movement left a long-standing legacy best captured by Dennis Banks, a founder of AIM and leader of the Wounded Knee occupation, when he said, "An awareness reached across America that if Native American people had to resort to arms at Wounded Knee, there must be something wrong…And Americans realized that native people are still here, that they have a moral standing, a legal standing. From that, our people began to sense their pride” (Hamilton, 2002).

     This identity pride was still palpable during a more recent national Indigenous direct action, the #NoDAPL movement.  The Dakota Access Pipeline route was changed in 2016 to cross under the Missouri River only half a mile up from the Standing Rock Sioux Reservation.  This was done after the U.S Army Corps of Engineers found that the original location outside of Bismarck, ND posed a significant risk to the municipal water supply (Estes, 2019; Isaacs et al., 2020).  The relocation of the route threatened the Standing Rock Sioux Reservations' drinking water. It also would run through treaty lands promised in the Fort Laramie Treaties of 1851 and 1868, and destroy 380 archeological sites, including sacred burial grounds (Estes, 2019).  April 1, 2016 marks the establishment of the Sacred Stone Camp, the first of the #NoDAPL camps, on LaDonna BraveBull Allards’ land.  By August, more than 90 Indigenous nations were present at the camp along with allies from around the world (Estes, 2019).  At this time, the Standing Rock Sioux called for tribes across the U.S. to help protect the waterway (Estes, 2019; Isaacs et al., 2020).  The growing influx of people spurred the creation of the next and largest camp established, the Oceti Sakown camp.

     Oceti Sakowin stands for the unification of seven nations of Dakota, Nakota, and Lakota-speaking peoples from Lake Superior's western shores to the Bighorn Mountain.  Oceti Sakowin gatherings were marked by a large fire surrounded by seven tipis or lodges arranged in a buffalo horn's shape.  Historically, these nations would gather together in celebrations such as annual sun dances, buffalo hunts, and trade fairs.  When the Oceti Sakowin camp was established to support the masses of people turning out to protest, it marked the first reunification of the seven nations in over one hundred years, the last time being before the Battle of Little Bighorn.  The Oceti Sakowin camp, at its peak, was the home to over 10,000 people, making it North Dakota’s tenth largest city at the time (Estes, 2019). The Oceti Sakowin camp's main road was lined with over 300 Indigenous national flags, representing the tribal nations in attendance.  The #NoDAPL camps were established to protect the water, but they turned out to be symbolic of much more than that.

     Since the beginning of colonization and the disruption of Indigenous ways of life, Indigenous people have heard stories about the “old ways.”  The #NoDAPL camps were built and operated upon Sioux principles and nonviolence. The spirit of Mni Wiconi (water is life) that guided the movement created an atmosphere where the stories of Native life, the “old ways,” came into existence once more.   Estes (2019) recounts Faith Spotted Eagle’s remarks on the camp culture, saying, “ I think it’s a rebirth of a nation. And I think that all of these young people here dreamed that one day they would live in a camp like this because they heard the older adults tell them stories of living along the river.  They heard them talking about the campfires and the Horse Nation, and they are living it.  They’re living the dream” (p. 58).  Without any contemporary infrastructure at camp, the infrastructure of Indigenous ways of knowing, living in, and being a part of the community had a place to exist.  This glimpse of native life had a mass impact on the surrounding Indigenous community.  There was an observed decrease in suicide-related behavior among Standing Rock youths in the months following the protest as reported by Monique Runnels who is Standing Rock's wellness director (Green, 2017).  Specific information and data on this decrease is not publicly available at this time due to confidentiality issues regarding the age demographic, which I discovered through extensive searches via the CDC website database. Additionally, the protest's direct actions had an immense psychological effect of empowerment, especially after facing centuries of violence (Estes, 2019). Overall, #NoDAPL offered a glimpse of a future where Indigenous people live in complete sovereignty guided by their elders and ancestors' principles, in harmony with the land and non-human relatives, in peace, and power.

     As outlined, Indigenous cultural resistance is part of a tradition.  Resistance is a source of Indigenous pride; it is the embodiment of the warrior in contemporary society. It began with the ancestor’s refusal to let their culture be destroyed and forgotten. Now, it is carried by the refusal to forget the history of Indigenous people, the ancestors' strength, and the continuation of their fight for liberation.  This fight for independence directly applies to scholarly work and those operating within the mental health field. As Brayboy (2006) suggested in TribalCrit, it is not enough to propose abstract theories and take passive action through research. The movement towards the decolonization of the mental health field is an act of resistance that needs to be taken up in more active and direct ways.  If these notable movements of resistance speak to anything, it is that we are a powerful presence when we work together for change.

     The examples in the previous section demonstrate that significant healing can occur when Indigenous people unite at historically significant locations.  This idea of healing through resistance on Native lands was qualitatively explored in a wilderness experience programming intervention by Schultz et al. (2016).  Informed by HT theory of intergenerational transmission through embodiment as discussed by Walters et al. (2011), Schultz et al. (2016) designed an intervention of walking a portion of the Trail of Tears titled “Yappalli.”  Six tribally enrolled Choctaw women between the ages of 21 and 49 participated in Yappalli. The walk began in Arkansas at one of the significant removal locations of Choctaw ancestors.  Participants walked 254 miles over nine days at a pace of 8-10 miles a day, based on the average number of miles per day the ancestors walked during their removal.  The participants followed the Trail of Tears' original path and camped on or near historical encampment sites.

     Curriculum cards containing Choctaw vocabulary, historical information about the upcoming portion of the route, and a reflection theme regarding health and cultural values such as “today we are being asked to reflect on cultural ways to address loss, grief, and trauma” were read aloud to the group each morning.  Measures for this intervention were pre- and post-walk in-depth interviews with participants and two additional focus groups with community members.  The interviews' coding revealed three themes of experience, reconnecting to the body, out of the head and into the body, and reflecting and reconnecting.  The research also suggested that reconnecting to ancestral histories in places of cultural and historical significance and emphasizing resilience narratives may provide unique opportunities for healing HT.  The researchers point out that not only did Yappalli function as an opportunity to honor the ancestral journey, but it also saw tribal members bodily recognize that caring for their health and tribal health is a way to honor the ancestor’s vision of health and prosperity.  One participant spoke of this dynamic, stating, “When I used to reflect on the trail, I’d think about literally the Trail of Tears. It’s all, this trail, the trauma, and the disaster for people. Now through this project, I’ve been thinking about it as not so much about being stuck in the trauma or the drama of the trauma, but it’s really to me become the trail of hopes and dreams that our ancestors walked this trail with a vision [of health] for us in mind” (Shultz et al., 2016, p. 13).  This renewed sense of purpose among participants resulted in sustained commitments to health changes.  Having such positive results from this novel study opens up possibilities for many interventions for HT. 

     Using historically significant locations as a site for a healing intervention is an act of resistance, especially when an intervention takes place at a location of trauma. As noted in the Shultz et al. (2016) study, it transcends the traumatic narrative by reconnecting individuals with their ancestors' strength and reminding them of the resilience of their tribe when faced with such adversity.  When coupled with the physical exertion of the present study, it allowed participants to embody their ancestors' challenges and experience their lived existence.  This deepening of connection to the body, mind, health, and place, through such lived experiences, reflects the individual's resilience and is a perfect space to do deeper emotional healing levels.  I hypothesize that holding healing interventions on locations of historical traumas is a grounding experience because participants get to connect their abstract thoughts and feelings of historical loss to a physical place.  Making the literal connection between location, historical losses, and symptoms will provide a unique environment to do treatment that involves individual processing, family processing, and ancestral processing.  Part of healing HT involves healing the “soul wound” and “blood memory” of Indigenous people that is the spiritual link to the HT.  As such, the merging of significant places with psychotherapeutic intervention is a promising new frontier for holistically healing HT.  And, as discovered by Shultz et al. (2016), healing at these locations invokes the tradition of resistance through reclaiming connection to Indigenous lands and tribal histories and promotes the protective factors of resilience, grounded in the strength of the ancestors and the culture that has protected for so many centuries, as discussed previously.

     To date, there have been few studies that look directly at HT and psychotherapeutic intervention.  Brave Heart (1998) created a culturally syntonic psychoeducational intervention to initiate historical trauma and grief resolution.  She hypothesized that education about historical trauma, a dialogue about the traumas and their effects with other members of the tribe with providing cathartic relief, and that psychoeducation initiates healing and promotes a positive group identity.  Brave Heart recruited 45 Lakota human services providers for her four-day intervention.  The intervention took place at a sacred Lakota location and consisted of four parts: didactic and videotape stimulus material regarding Lakota trauma, a review of the psychology behind unresolved grief and trauma, small group sharing facilitated by a Lakota male and female pair, and a Lakota purification ceremony and wiping of the tears ceremony.  Brave Heart found a reduction of grief affect post-intervention, specifically in the helplessness and hopelessness, guilt and shame, sadness and anger components of the questionnaires. Additionally, all participants reported more positive feelings about their Lakota identity (Brave Heart, 1998). 

     Brave Heart et al. (2020) conducted a follow-up study utilizing the four-part intervention aforementioned.  The four-part intervention was redefined as Historical Trauma and Unresolved Grief Intervention (HTUG) and was modified to occur over 12 weeks instead of a four-day retreat.  For this study, Brave Heart et al. (2020) wanted to compare the efficacy of  HTUG plus Group Interpersonal Psychotherapy (IPT) in lowering depression and increasing group engagement versus IPT only.  The study took place in two different tribal communities, a northern plains reservation site, and a southwest urban clinic.  Fifty-two Indigenous participants with a mean age of 43.45 were randomized into one of the two interventions.  Both interventions ran for 12 weeks.  The data showed that HTUG+IPT and IPT only interventions effectively reduced depression with no significant difference between the groups.  However, HTUG+IPT participants demonstrated significantly greater group engagement, and clinicians expressed a preference for this intervention based upon their personal observations of participants.

     These studies highlight barriers to treatment that need to be acknowledged to move forward in decolonizing mental health.  First, Brave Heart et al. (2020) directly acknowledge that conducting such studies is difficult because there are not enough Indigenous identifying mental health care providers.  This extends to providing culturally informed and responsive mental health care outside of research as well.  Hill and Barlow (2021) cited that there are roughly 300 Indigenous identifying mental health care professionals in the United States to serve a population of close to 6.9 million people, far too few professionals for the population they serve. 

     Second, due to the extensive history of colonization and oppression, Indigenous communities rightfully are distrustful of science, research, and health care (Doria et al., 2020).  The distrust of white people and institutions was empirically validated by Whitbeck et al. (2004).  Thus, Indigenous people and communities are wary of participating in research or seeking mental health care due to fears that they will be oppressed, the findings will be weaponized against them, or that their culture will be exploited or appropriated (Lucero, 2011, Venner et al., 2012; Blume, 2020).

     Third, another barrier relevant in Brave Heart et al.’s (2020) study is the use of evidence-based practices (EBP). The general approach to treatment is to use EBPs developed from colonial perspectives of mental health (Blume, 2020).  EBPs are rarely tested or validated for Indigenous communities because the Theory of Clinical Trials explicitly states that subpopulations do not need to be separately analyzed unless an empirically provable hypothesis about group differences exists.  Since there has been so little research on group differences for DSM diagnosis, or based on other mental health phenomena such as HT, there isn’t much empirical research to suggest that Indigenous people are not represented by the samples used for EBP clinical trials.  Indigenous people are also frequently not included in a “representative sample” for clinical trials because they are an invisible minority and generally forgotten about.  When Indigenous people are part of the representative sample, they are not included in significant enough numbers for subgroup analysis of treatment effects (Lucero, 2011).  Beyond the inadequacies in the actual research, the first line of treatment implementation is to  “culturally adapt” the EBP in a top-down approach that incorporates community knowledge into the existing framework (Blume, 2020).  This practice's fault is that it is trying to bend colonial ideas to better fit within Indigenous treatment. 

     While culturally adapted EBPs can report efficacy, the present discussion would not be warranted if they were genuinely useful. This is particularly salient as many imported treatment models do not align with traditional understandings of health, wellbeing, or healing, which was cited by Venner et al. (2012) and Doria et al. (2020) as being a significant barrier to seeking treatment.  One such issue with imported EBP treatments is that they frequently advocate for removing oneself from potentially damaging relationships, communities, and other environments that may be contributing to distress as a part of the healing.  As noted, Indigenous people find remarkable resilience from being embedded in their culture and community. These sites also serve as a locus for a great deal of distress.  It is not reasonable to ask for an Indigenous client to sever ties with inherently protective spaces.  Western models of treatment are also not cognizant of the protective family and community factors that would benefit a client.  Therapeutic treatments operate under the assumption that care should be focused on the individual alone.  Indigenous perspectives are grounded in a worldview that sees connectivity between living and non-living within an interdependent system (Blume, 2020).  Individuals cannot be isolated from the whole, and as such, individual treatment, and whatever results stem from that treatment, is incomplete. This points to the need for treatment models that have healing components at the individual, family, community, and even spiritual/ancestral level.  A truly culturally grounded treatment would have modules that account for these levels of experience and promote engagement within the interdependent system. 

     The previous paragraph addresses the shortcomings of culturally adapting EBPs, but it also brings up a much more difficult research problem.  To receive funding to do research, the use of an EBP is generally required (Lucero, 2011).  Indigenous communities hold a wealth of knowledge about traditional healing practices for mental health, but these practices cannot be studied because they are not documented to EBP standards.  In continuity with the distrust of research, communities are not eager to document such practices because they are sacred, and sharing them runs the risk of appropriation and destruction (Lucero, 2011).  Furthermore, Western science entirely rejects metaphysical explanations as they are beyond human perception, and as such, spirituality is often absent from treatment frameworks.  Beyond the hesitancy to document traditional practices for the reasons outlined above, it is also difficult to justify funding research grounded in spiritual perspectives of healing since the effects are not entirely measurable.  Obtaining funding is a truly immense barrier to creating novel culturally grounded treatment and making treatment available within communities.  Indigenous health care is the least funded federal health care program, below even prisons (Venner et al., 2012; Doria et al., 2020; Hill & Barlow, 2021).  Also, the majority of Indigenous people, 78% according to the 2010 U.S Census, live in urban areas, but less than 1% of Indian Health Services funding is allocated to urban health centers (Doria et al., 2020).  The severe inequity in access to care and resources needs to be remedied to move forward in healing HT and its’ causal health problems.  

     The lack of Indigenous identifying professionals within the mental health field and the distrust in science, research, and health care due to histories of oppression make current and future research quite difficult to conduct.  Furthermore, parameters set by the mental health community, such as the use of EBPs and requirements for funding, confine the scope of potential research and limit treatment options within clinical practice.  The parameters set upon research and care also reinforce the oppression and subjugation of Indigenous people.  These are just some of the barriers facing Indigenous mental health care that need to be addressed to improve care and health equity.  The cycles of HT, oppression, and health inequity need to come to an end, now.  While it may seem daunting, in the following section I will discuss potential ways to overcome some of the many barriers through systematic decolonization.

     Decolonization is the process of reversing colonization, specifically assimilation, through restorative procedures that directly address the losses of culture, language, land, resources, religious freedom, political autonomy, to name a few (Freire, 2000; Hartmann & Gone, 2014; Nutton & Fast, 2015; Burnette & Figley, 2016; Blume, 2020).  Decolonization, at large, is active resistance, and as such, research that presents anticolonial views and practices are in and of themselves acts of resistance.  As such, HT was introduced as an anticolonial initiative by Indigenous healthcare providers within psychology to empower Indigenous people to overcome  legacies of colonization (Brave Heart & DeBruyn, 1998).  The research around HT strives to highlight pervasive effects of colonization and rewrite the narratives around the causes of Indigenous health inequities.  HT research shows that these health inequities can be better addressed by first focusing on the root cause, HT.  This is accomplished through decolonization. Decolonization of treatment needs to be addressed in a bottom-up approach from the minutia such as language, to overall terminology, and upwards to creating novel interventions that are grounded in Indigenous healing knowledge. 

     To begin, Linklater (2014) suggests decolonizing the term “trauma” as a primary step toward decolonization of mental health care.  Trauma is an inherently westernized concept that implies individual responsibility for the response rather than accounting for a vast number of external influences that directly impact the individual reaction (Linklater, 2014; Hartmann et al., 2019).  This ideology plays into a larger issue with the medical field for minorities in general.  Scientific methodologies were initially created to find the biological inferiority of minorities.  These scientific methodologies gave rise to the idea of “blood quantum,” which is still used to determine tribal enrollment.  Blood quantum has been weaponized to deny benefits, including healthcare, to Indigenous peoples who do not meet a threshold of “Indian-ness” and further invalidates Indigenous identity and self-determination (Lucero, 2011, Garrett et al., 2013).  The term “trauma” similarly invalidates Indigenous experience by inferring victimry and responsibility for the trauma and response.  The term Historical Oppression (Burnette & Figley, 2016; Burnette et al., 2019; McKinley et al., 2020a) is being used in more contemporary research to account for both HT and ongoing structural violence such as discrimination, microaggressions, and marginalization.  Historical Oppression may be of interest for use in place of HT in future research to avoid the issues presented by the word “trauma” and to expand the concept of HT to be more inclusive of social and systemic processes that underly and perpetuate transmission.  That being said, I would also accept a decolonization of “trauma” by redefining it as a term that stands for all reactionary processes stemming from any injurious experience in a way that is clearly distinct from pathologized trauma seen within mental health diagnosis manuals such as the DSM.  

     One way to obtain more funding for research on HT is for the theory to become a broadly accepted clinical condition in the form of a classified DSM diagnosis.  Beyond funding for research, having a defined diagnosis often creates greater access to health benefits and special services for the individual.  While well-intentioned, the downside of creating a diagnosis is that it places HT within the westernized pathology dynamic which has potential for perpetuating internalized ideas of “badness,” “wrongness,” and identity shame, which are the same issues that arose with the conceptualization of HT as a clinical condition in research.  One possible way to mitigate this potential outcome is to not rely upon a pathological or negative manifestation to validate the presence of HT. As Denham (2008) demonstrated, alternative resilient expressions protect against HT but are still very much a part of the HT experience.  These alternative expressions do not weaken HT as a construct but rather speak to a need for a greater understanding of individual and collective trauma experiences to inform culturally relevant responses (Denham, 2008).  HT is a fundamental cause for persistent and widening Indigenous health inequities, but HT responses are not linear across peoples.  Any proximal event can elicit an HT response.  Vice versa, not all proximal events will elicit an HT response.  The HT response is contingent on several not entirely understood factors yet, as per Denham (2008).  Nutton and Fast (2015) echo this sentiment acknowledging that further research is needed to identify decolonizing strategies and positive coping methods that buffer the HT experience at the individual, family, and community levels.  While still highly qualitative, resilience research is advancing the discussion around HT to be more inclusive of the prominent protective factors of family connection, community connection, and cultural connection.  These strengths already exist within the language and lived an existence of Indigenous communities, and as such, can serve as a launching point for creating decolonized diagnoses and therapies. If HT is designated as a diagnosis, having a strengths-based conceptualization behind it will combat the potential negative associations and internalizations of pathology by imbuing it with language that empowers positive responses such as resilience over negative responses, much like reframing the term “trauma.”  A strengths-based conceptualization is aligned with decolonization vis-à-vis Freire’s path to liberation (2000), Brayboy’s call for centering of Indigenous strengths (2006), and Vizenor’s survivance (2008).

     Another level of decolonization work that needs to occur is a systematic look at the meaning of all DSM mental health diagnoses for Indigenous communities.  Findings from Whitbeck et al. (2009) directly point to why DSM diagnoses need to be evaluated for decolonization of mental health pathology.  Whitbeck et al. (2009) tested the Historical Loss and Associated Symptoms scales against the Center for Epidemiologic Studies Depression scale for confirmatory factor analysis.  Their findings suggested that perceptions of historical loss including depressive symptoms are related to but distinct from the Western depression construct. This is an important finding and distinction because treatment for depression is constructed around the validated definition of depression. Thus, it will not adequality treat a depression that is linked to historical losses and the associated manifestations cognitively, somatically, and spiritually.  Also, Blume (2020) notes that substance use for Indigenous individuals is likely a form of negative reinforcement/self-medicating rather than a high-seeking behavior.  It fulfills the function of feeling normal in the face of oppression and trauma rather than seeking positive feelings associated with a high.  It can also offer an alternative community to feel a sense of belonging in, space where personal power and meaning may be derived from participation in the culture of use, most specifically that of alcohol and the drinking community (Blume 2020).  These studies speak to the need for further research that examines DSM diagnoses for cultural meaning and relevance.  Having a better understanding of mental health disorders' cultural praxis is not only an act of decolonization but offers a culturally relevant lens from which to treat from.

     In continuation, further examination of DSM diagnoses should also include a critical look at the consequences of colonialism, how they interact with the manifestation of disorders, and operate as a social determinant of disorders.  Including specific sections on colonization effects within the DSM is a step towards decolonization of mental health pathology.  Mental health professionals likely have a general understanding of the effects of colonization, but do not make the connection between historical challenges, contemporary experiences with colonial oppression, and presenting mental health disorders (Blume, 2020).  The DSM has sections under each diagnosis discussing the development, progression, and potential cultural factors that influence a diagnosis.  There is room to flesh out critical points of colonial influence on a diagnosis so that a clinician, even one with little experience working with Indigenous clientele, will be attuned to these underlying influences from the start of evaluation and treatment.  For example, Separation Anxiety Disorder is conceptualized as having root in parent-child attachment and early childhood adverse experiences.  While these loci have applicability for Indigenous peoples, the cultural conceptualization could be expanded to address colonization and HT links such as ancestral removal from native land and boarding schools which were traumatic separation experiences that could be contributing to the manifestation of the disorder in the individual, whether or not they directly experienced them.  This conceptualization also would impact treatment, as attention could be directed at healing past and present influences of trauma.  This idea once again highlights the need for a deeper level of emotional processing work facilitated by the treatment and the clinician in congruence with my prior discussion in the section “Incorporating Resilience and Resistance into Mental Health Treatment.”  

     Another step toward decolonization and improvement of the mental health field is to ground treatment and interventions within Indigenous knowledge.  Therapeutic intervention for HT and other mental health disorders needs to begin with an Indigenous paradigm that will result in a best practice for the Indigenous individual, family, or community.  While one could argue that tribes are too disparate to create universal treatment frameworks, Garrett et al. (2013) outline at a fundamental level common beliefs, values, and practices shared amongst Indigenous people.  First and foremost, they reiterate the common core belief that the tribe is an interdependent system of people who see themselves as connected members within a greater whole, not individual units. This greater whole of the tribe is interconnected with the surrounding natural environment and as such, though. Identity is defined not only by human-to-human interaction but also human to non-human (animal) and human-to-nature. These connections/relationships are essential for an individual’s wellbeing.  Some common core values shared by Indigenous tribes are harmony with nature, cooperation, community contribution, sharing, acceptance, reliance on extended family, kinship, and deep respect for elders, to name a few (See Garrett et al. 2013 Table 1 for a detailed list).  Garrett et al. (2013) also describe several fundamental spiritual beliefs: there is a single higher power known as Creator (other names included in the article), and there are lesser beings known as “spirit beings or helpers”; humans, animals, plants, and all other organic materials are part of the spirit world; the spirit world exists side by side and within the physical world; humans have a body, mind, soul, and spirit that are interconnected; wellness is defined by balance and harmony between body (physical), mind (mental), soul (emotional), and spiritual levels of existence; unwellness is the result of an imbalance between these parts.  Garrett et al. (2103) have outlined basic but convenient principles that can be used as a preliminary framework for creating decolonized treatment, primarily because research heavily advocates for the inclusion of traditional spirituality and traditional practices. Doria et al.’s (2020) study found that participants wished to see the inclusion of traditional spiritual and healing practices into mental health treatment as well as having a “Native healer” or “spiritual advisor” to support their wellness journey.  The participants also felt that having these components in treatment would promote help-seeking and service utilization within the community.

     The mental health field has made some progress towards including Indigenous paradigms with the recent and significant push for community-based participatory research (CBPR). CBPR is an approach designed to engage the local community members in the development and implementation of interventions/treatments.  CBPR allows community members to identify their needs and advocate for the type of healing they wish to see occur from the interventions/treatments.   CBPR also functions to bolster communication between researchers and community members, builds trust between researchers and participants, and positively affects participation in research (Enoch & Albaugh, 2016).  Research across the board has shown that culturally grounded treatments that involved community and family participation in the creation resulted in more positive outcomes (Doria et al., 2020). While CBPR is a promising step forward for empowering Indigenous self-determination in treatment, CBPR is more time-consuming and increases costs, making it hard to implement, especially when funding is limited (Enoch & Albaugh, 2016). 

     Finally, decolonization has to involve creating equity in funding for treatment research and treatment centers so that all Indigenous people have access to the care they need.  Indigenous people, including researchers and clinicians, should have the right to make decisions regarding mental health care, based on what has worked and what will work, without worrying about limitations on funding, such as having to use EBPs for research or treatment for it to be funded.

     Recurrent attempts at destruction and erasure mark Indigenous history of the United States.  From the many traumas perpetrated against Indigenous peoples, the phenomenon of HT has been defined as a root cause of the vast number of health inequities seen within the Indigenous population.  HT research is very new, and more work needs to be done to define the phenomenon better, identify direct effects, and create specific therapeutic treatments for HT and resultant health outcomes.  It can be reasonably assumed that treating HT directly will reduce the number of health inequities, specifically those related to mental health.  This research must come from a decolonized perspective to not perpetuate settler-colonial oppressions, especially that of pathology.  HT is also not reliant upon negative health responses.  As the current discussion points out, Indigenous people have demonstrated their survivance through resilience and resistance that protects individuals, families, and communities from the more detrimental HT outcomes.  In and of itself, research expanding upon HT is an act of resistance and is decolonized in nature since it educates the field on Indigenous experience.  While there is an inherent risk, as outlined, it is necessary to improve the mental health status of Indigenous peoples across the nation for pursuing this line of research.  The research also highlights the immense protective nature of Indigenous culture, from traditional activities to kinship and stories of overcoming adversity, and how those areas of strength are an excellent locus from which to build decolonized treatment.  This paper aims to present a decolonization argument that rests on the importance of Indigenous knowledge for healing and advocates for expanding the dialogue around, and addressing the inadequacies of, the mental health field.  To achieve decolonization and healing, Indigenous people need to be at the forefront of developing the theories and practices of HT for the benefit of their communities and Indigenous and non-Indigenous health care professionals alike.

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