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Layers of loss, death, and grief as social determinants of Lakota elders' behavioral health.

Introduction

There are 5.2 million people in the United States who identify as American Indian (AI) and Alaska Native (AN), either alone or in combination with other races (Norris, Vines, & Hoeffel, 2012). Within this population there are 2.9 million people who identify solely as American Indian and Alaska Native. Of note, 67 percent of the American Indian/Alaska native population lives outside of reservation or tribal lands. There are over 569 federally recognized tribes in thirty-five states, with the highest percentage (43%) living in the western region of the United States (Norris et al., 2012).

The overall life expectancy of American Indians is 73.5 years compared to 77.7 years for the U.S. population (U.S. Department of Health and Human Services, 2014). According to McFall, Solomon, and Smith (2000), only 60 percent of American Indians live to reach their mature years, as opposed to 86 percent of the white population. Given the diversity of Indian Country, the life expectancy and chronic disease rates vary by region. Life expectancy, which is 76.3 years in the Indian Health Service (IHS) California area, declines to 64.3 years in the IHS Aberdeen area, serving North and South Dakota, Nebraska, and Iowa (Moulton et al., 2005). Furthermore, American Indian men living in the IHS California service area live nearly eight years less than females (63 vs. 70.6 years; U.S. Department of Health and Human Services, 2010). Further investigation is required to determine the causes of these regional differences. The three leading causes of death for American Indians are heart disease, cancer, and accidental injuries (U.S. Department of Health and Human Services, 2014). Additionally, American Indians experience higher rates of chronic disease related to diabetes, heart disease, obesity, and chronic respiratory diseases (U.S. Department of Health and Human Services, 2014). It should be noted that health statistics for American Indians are inaccurate because of significant gaps in reporting and misidentification of race related to health reporting (Moy, Smith, Johansson, & Andrews, 2006).

Bereavement and Grief

Experiencing loss of loved ones is a normal aspect of the aging process. Bereavement is the experience of having recently lost a significant person through death (Shah & Meeks, 2012; Smith, Nunley, Kerr, & Galligan, 2011). Grief is the emotional and social distress resulting from bereavement (Choi & Gonzalez, 2005). Older adults experience the widest variety of bereavement in terms of type of relationship to the deceased (Shah & Meeks, 2012). Late life bereavements include loss of spouses, siblings, children, peers, or a parent and depend on the connections to the social and familial network (Shah & Meeks, 2012). Bereavement is associated with a higher risk of mortality; higher negative consequences of physical, social, emotional, and mental health functioning; and increased use of medical services (Kersting & Kroker, 2010; Shah & Meeks, 2012). Women are at a higher risk of experiencing bereavement because of their longer life span (Kersting & Kroker, 2010; Shah & Meeks, 2012). Bereavement is a naturally occurring event in people's lives. It appears to occur more frequently and at younger ages among American Indians than among the general population, although no statistics exist to corroborate these beliefs. Because of the amount of loss experienced at a young age and extending across the life span, grief and bereavement cannot be overlooked as a determinant of behavioral health that will address the mental and emotional health in American Indian elders.

The relationship between loss and the health experiences of American Indians, as well as the social and economic context of living on a reservation, precipitated an in-depth exploration into the effects of these losses on the health experiences across the life span of Lakota elders living on the Pine Ridge Indian Reservation in South Dakota. American Indians define health holistically and include mental, physical, emotional, and spiritual health. The following research question was examined: What are the experiences of Lakota elders with health, wellness, and illness? Throughout the elders' narratives regarding their life experiences with health, multiple losses of loved ones were a prominent theme and contributing factor to their behavioral health.

Methodology

Participant Characteristics

Twenty-five Lakota elders living on the Pine Ridge Indian Reservation in South Dakota participated in semi-structured, in-depth, face-to-face interviews or conversations. These conversations were recorded and lasted from one and a half to nine hours. Twenty of the elders were women (all widowed or divorced), and five were men (three married, two single). They ranged in age from fifty-five to ninety-eight years, with three under the age of seventy. All but five spoke Lakota as their first language and often communicated with each other in Lakota on a regular basis. At the time of the study, all but three of the elders resided on the reservation (two lived in a nearby city to access resources for their grandchildren and one lived in a long-term care facility). All had been born on the reservation and attended day school or the reservation boarding school.

Characteristics of the Pine Ridge Indian Reservation

The Pine Ridge Indian Reservation, the home of the Oglala Lakota Indians, is located in the southwestern corner of South Dakota along the Nebraska border. There are roughly 46,855 tribal members (U. S. Department of the Interior, 2014). For the 2000 Census, the population of the reservation was reported as 15,521; however, census figures are inaccurate because the population is rural and many people are overlooked. In 2005, the Federal Department of Housing and Urban Development accepted the results of a study by Colorado State University that reported a population of 28,787, although the executive director of Oglala Sioux Lakota Housing stated that the population was closer to 40,000 (Crash, 2005).

According to the 2000 U.S. Census, Shannon County was the second poorest county in the United States with unemployment on the reservation reaching nearly 80 percent; 49 percent of the total population on the reservation and 61 percent of children under the age of eighteen lived below the federal poverty line. Also according to the 2000 U.S. Census, the median household income was $20,916. The per capita income for Shannon County was $6,286, and the annual income for 26.7 percent of households was less than $10,000.

Recruitment and Data Collection

In order to conduct a study with Lakota elders, the methodology and research design must be respectful of their cultural and social position. Therefore, this study employed Indigenous Research Methodologies, the theory and methods of conducting research from the standpoint of an Indigenous epistemology (Kovach, 2009). Indigenous research methodologies are born out of Indigenous relationships--to each other, to their ancestors and families, to their environment, their spirituality, ideas, wisdom, and traditions that have supported the living on this land for centuries (Wilson, 2008). The author conducted all the communication in the study, including setting up the interviews and visits as well as the recording of the elders' stories. The author used convenience sampling by networking the contacts of tribal members she had made over the years; they generated a pool of Lakota older adults by referring her to their friends, family, and acquaintances (Weiss, 1994). For this study, the author visited the Pine Ridge Indian Reservation for several years, participated in many community events, and developed relationships with several families currently living there. They began with this network and they recommended family members to the study. They discussed the project with their elder family member and then, upon their consent, the author contacted them to schedule the interview. Additionally, snowball sampling was used when the elders recommended others to participate in the study. Also, there are nine districts on the reservation, each with a senior center and elder congregate meal site. The author visited each of those and recruited elders directly by introducing herself and the aims of the study, and then answering their questions.

After meeting in a place that was private and convenient for the elders, the author employed a Conversational Method, which provides a "culturally organic means to gather knowledge within research" (Kovach, 2010, p. 42). The Conversational Method offered the Lakota elders greater control over what they wished to share with respect to the research questions; hence, the method acknowledged, incorporated, and operated within the parameters of their cultural norms (Kovach, 2009). The interviews consisted of open-ended exploratory questions about their life history and experiences that affected their health and well-being. The elders were able to direct a story toward a question. This relational methodology allowed for reciprocal give and take, as the author and interviewees questioned each other to gradually create a mutual interpretation of a topic or an idea. Kovach (2010) notes that this give and take deepens the shared insights, builds richer relationships, and causes the researcher to become an active listener.

Data Analysis

The interviews were digitally recorded, transcribed verbatim, and then manually reviewed for reporting patterns or themes (Braun & Clarke, 2006). An inductive approach was used to apply descriptive codes to stories without a preexisting framework in order to develop themes and patterns across the narratives that described the mental well-being of Lakota elders. The author wrote memos defining each theme and how this fit into the overall "story" of each theme to further refine the emerging themes. These analytic efforts resulted in descriptions of the losses the elders had experienced. Several elders experienced many deaths over their lifetimes, losing their mother, their siblings, their children, and their spouses as a result of limited access to health care, high rates of health disparities, and accidental deaths.

Results

The Lakota elders experienced many losses of loved ones and community members across their life spans. They grew up with very limited formal health care. There was one physician in the clinic in Pine Ridge that served the entire reservation until the IHS began to develop services after 1955. The elders were born into large families with many siblings. There were losses due to illnesses. One female elder in her nineties, Elder 1, narrated the loss of a sibling as follows:

Elder: Yeah, we lost one. I lost my little brother. He was three and a half when he died of ... um ... bronchitis.

Interviewer (author): He died of bronchitis?

Elder: Bronchitis.

Interviewer: Were there doctors then? When you got sick, what did you do?

Elder: Our parents, um, doctored us themselves. They had some of the darndest remedies.

The elders lost siblings throughout their lives. One elder woman, Elder 7, shared, "I don't have no relatives--no sisters, no brothers, no husband, no dad. I'm alone.... I'm the only one who lives and they all died." She was not the only elder in the study who had lost all of her siblings. Elder 6 said, "Well, I had six brothers and one sister but they're all gone now. [I'm] the only one left." The Lakota elders could readily list the family members who had passed away. Often the list was long. One of the younger elders, Elder 12, shared,
   I have ... uh ... one younger brother who passed away when he was
   eighteen; he drowned. I had one brother who passed away years ago,
   he died of a heart attack--and I had an older sister that passed
   away in '87 in a car accident and so there was only five brothers
   left and two sisters left of the original ten


The elders have lived in a social and economic context that resulted in deaths of their siblings beginning in their childhood and continuing through to adulthood as a result of health-related issues and accidental deaths. This same pattern persists in the loss of their parent or primary caregiver.

Loss of a Parent

The loss of a loved one, especially a primary caretaker, brought about a period of instability in the young lives of the elders. One loss often led to a loss of resources and added complications related to education and ability to work. A few elders lost their primary caregivers when they were very young, some from health-related issues such as cancer, tuberculosis, or childbirth. As one elder woman, Elder 4, shared:

Elder: Mom died in 1942. They always told me she had tuberculosis and here we were making a family tree and one of Aunt Katie's daughters, Aunt Katie was the youngest of all of them, she had the hospital record and she died of childbearing, or whatever.... And that was when Sioux San was the tuberculosis hospital. She died there and they all said that. That was just when?

About April or something, that's when I found out she died with TB, all those years she died of that.

Interviewer: How old were you when your mom died?

Elder: Six.

Interviewer: And she was how old when her mom died?

Elder: She was, I think they said Aunt Katie was thirteen and she must have been sixteen or seventeen.

Interviewer: The moms died young. What was it like not to have her?

Elder: Awful. I see the way some of these people treat their moms and I said I'd give my right arm to have mine. It's, there's something that is gone. Like it's lost. You feel like you are lost. I think it's terrible. I don't know.

Often when a mother died and there were young children left behind, other family members stepped in and helped raise the children. One of the elders, Elder 3, lost her mother and her grandmother helped her father raise her. Even today her grief for both her mother and grandmother is palpable. She shared:
   So she suffered, suffered for three days and she left us. I didn't
   even notice that. "Where's mom at? Where's mom?" I was looking
   around. They didn't know what to say. It was a sad thing [starts to
   cry and get choked up but keeps talking]. They all came to me and
   said, "Mom's gone." I said, "ok".... So she's gone. She left us.
   So my grandma raised me.


After losing her mother, her father went on to remarry, but Elder 3 did not get along with her stepmother and formed a tight bond with her grandmother. Her grandmother passed when she was only nine years old:
   Then I lost my grandma.... She got sick. We tried to take her to
   the hospital but she said, "Noooo, I'm alright, I'm alright." Ok we
   live right there in just a little tent, that's where she lives. She
   didn't want to go inside. Me and her we stay there. We sleep in
   there. I went back in there and talking. She laid down, you know.
   She'd just lay down sideways. I said, "Grandma you going to bed?
   Going to sleep?"

   "Yeah, I'm tired. Tired, I'm going to lay down for awhile."

   "Alright."

   I went out there to go see my dad. But he said, "Go watch Grandma,
   go watch Grandma, go watch your Mom."

   I told my dad, "Come and help me. Can't even wake Grandma up. She's
   really sleeping good. Helping me get her up or something." He went
   in there and touch her pulse and it was stopped ... she died in her
   sleep. She was about ninety-three, I think. She was really old. He
   said, "Baby, Grandma's not here. Grandma is not going to be around
   with us anymore" [pause for crying quietly, deep breathing,
   sniffling].


This particular elder did not fully recover from these losses, and as she shared her stories, the pain and grief came through in tears and sobs. She has carried the pain of losing her primary caregivers for six decades. These losses have permeated her life in that she was unable to finish school, leaving in the sixth grade because her family could not afford for her to go on. She struggled to support herself and her family with few job opportunities.

The youngest elder in the study, Elder 12, experienced several challenges that were layered over time, creating a very difficult childhood that left lasting emotional effects on him. He stated:

Elder: I grew up in two places: in Batesland in the summer and boarding school in the winter, fall, winter, and spring. I went to the boarding school as soon as I turned six, soon as I turned six, and I graduated when I was eighteen. Now one year, I was in San Jose, California, my sophomore year. I stayed with a friend of a family after my mother died when I was fifteen and then I came back and finished my junior and senior year. My dad was a farm laborer; earlier on, he owned his own ranch and something happened with the tribe and they had to sell the cattle. They took all our cattle and sold it. Never reimbursed him, so after that, he went to work as a laborer--a farm laborer and the rest of, all the rest of us went to work in ranches. Early in life,

I drove tractors and worked on a ranch.

Yeah. That's where, that's where a lot of my problems started when I went to boarding school, when I went they, they didn't want us to speak our language, and we were ostracized for speaking our language. They basically put us in a Marine boot camp when I was six years old. I'd have to stand up and fix my bed in the morning and stand at attention and, uh, march us to the dining room, march us back, cut our hair off, made us all dress the same, and uh, a lot of fights.

Interviewer: Amongst the kids?

Elder: Amongst the kids; sometime, it was encouraged by the staff.

Interviewer: Really?

Elder: Yeah. A lot of you can't express yourself. It was like a little prison or boot camp and I shut down and on top of that, everything I read when I was at that boarding school listed us as savages--the history books. Yeah. So I had an identity crisis there early on. At the boarding school, you are only served three meals a day; if you miss, you will have to starve until the next time. There were two hundred boys in that dormitory.

Interviewer: Was it scary?

Elder: Yeah, it's many boys you don't know. There's a lot of bullies. There's a lot of gangs and then was a lot talking, a lot of name calling. A lot of misguided--just like when you go into penal institution the same rules apply. Early on, I learned not to express my feelings. I learned to stuff everything for fear that I would be labeled as a sissy, somebody that--you had to keep your rank, the pecking order. Anytime you throw people together, you have to have a pecking order. That's how it was. It was very confusing over the years. I didn't even know what I did wrong for all the name calling I got, and for being a full blood. I didn't understand why it was bad, being a full blood. I didn't understand why it was bad to speak my language. Everything I was taught seemed like it was bad when I went to the boarding school. So there was a lot of fear involved and uh, a lot of ... a lot of resentment. A lot of rage.... And then it was safe, we'd go home on the weekends sometimes and it was safe at home. Go back to my traditional ways; my grandma, mom and dad and that's what probably really helped us out. My family at least was the structure at home. All of us are full brothers and sisters and uh, and uh, we didn't have TV We didn't have any electricity or running water. We had a wood stove and uh, there was ten of us in that log cabin.

It is significant to note that this elder lost his mother and then the stability of living on the reservation. Meanwhile, his family lost their livelihood with the loss of their farm animals, adding another layer of loss. Also, by attending boarding school, Elder 12 felt a loss of identity and connection to the family on a daily basis. The violence and the trauma he experienced at the boarding school were counterbalanced by the knowledge and comfort of the home nearby. Even though the home lacked the basic amenities, it nevertheless provided much needed emotional comfort and safety away from the violence at the boarding school. Elder 12 also noted that his grandmother was a very important resource for culture and support; she lived on the same plot of land and interactions with her occurred regularly.

The connection to their grandmothers was often an important and pivotal relationship. Many of the elders attended boarding school on the reservation, but one elder, Elder 20, had a very different upbringing as a result of acquiring tuberculosis when she was a small child. Her story is of particular importance because of the high prevalence of tuberculosis in American Indian people. Also, her story shows how the families had many pressures on them: the strain of poverty and limited resources, multiple children in the home to raise and care for, a sick child hospitalized more than a hundred miles away, and travel by horse and buggy. With these pressures, it was impossible to maintain connection to the child who was hospitalized so far away. She shared her experiences:

Elder: Geez until I was ... when I was five, I didn't know I had tuberculosis and I grew up in the Sioux San until I was twenty. I didn't even come back. So, I think when I was four, I think I had that but they didn't find out until I was five and I was really sick then. I knew I had fevers and I was cold and I slept a lot.

Interviewer: What is Sioux San?

Elder: It's a hospital.

Interviewer: You grew up in a hospital?

Elder: They didn't even come back.

Interviewer: And then you left when you were twenty?

Elder: I came back when I was twenty years old.

Interviewer: Did you see your family?

Elder: Huh uh. They never even came up. That's why I don't hardly know them. I don't know my sisters or brothers. I just know their names.

Interviewer: How many are there?

Elder: There's thirteen.

Interviewer: Thirteen kids and you are the oldest?

Elder: Second to the oldest. So yeah, there are thirteen and out of there I am the only one that got sick. I was born at home and they said maybe in those days I might have caught it from my grandma; that's how my grandma died after she raised me. I've been around her and she died with that in 1949. She died of tuberculosis. No other problems, except that. They said she was healthy but then she I think she had that that time. So I caught it.

Elder 20 lost her grandmother, who was a primary caregiver, and then became ill herself. As a result of this illness, Elder 20 lost the connection to her family, school, and her reservation community. She shared that there were Lakota nurses working at the hospital who helped her learn to read and sew; however, she was left to work through the confusion and grief that resulted from these losses that framed her childhood.

Many of the elders also encountered frequent illnesses in their immediate families--illnesses that often descended upon them very rapidly, frequently ending in death. A case in point is Elder 22, a woman whose parents were older when she was born. She took care of her parents when they were challenged by health issues. The health issues that eventually robbed her of her family were often related to heart disease. Such losses occurring during a short time created significant emotional trauma. She recounted how these losses suddenly emerged, causing her to literally run for help:
   My mom likes to sew and here we were sitting [I was sitting] beside
   her and looking at her and something happened, and here [my dad]
   was slumped over and I ran in town it was, that wasn't the road
   that time.... What did they call them? They are like CHR, but it
   was another name. There was a colored woman that lived in town. It
   was on a Sunday, Fourth of July was on a Sunday that year. When I
   was running, I could see my dad lying on the ground face down. I
   told her, and I told her that my dad was old, but he was tall, but
   you better get help; my dad is a big man and here at that time the
   police had to come all the way from Pine Ridge [100 miles away] if
   anything happened. They had to come all the way from there. And
   here, somehow there was one in town and they came back, and my mom
   was sitting, and she was just crying, and he died then--a heart
   attack. I went to save him, and just ran in town. Almost
   eighty-nine years old. And I lost my mom when she was eighty-six.


(The CHR is a community health representative, a tribal paraprofessional who worked in the community, assisting with education, transportation, and health matters.) This elder had left high school in order to provide in-home care-giving assistance to her aging parents. In the resource-limited environment, individuals fill in the gaps by sacrificing their own lives to care for their loved ones. Additionally, it was a cultural practice to care for their elder family members.

Loss of Children

Unfortunately, American Indian people have high rates of accidental death, often leaving children without parents. The elders have been there to pick up the pieces. Elder 7 shared her story:
   One daughter had a car wreck and died and this one [grandson, now
   thirty] was eight months old and another one was five years old,
   and I raised both of them. Her mom was working at ... uh ...
   [inaudible] for I don't know how many years, but these two were
   raised by Social Security when I had them. Their mom was a jailer,
   and she had a car accident and died, and these two were getting
   Social Security and I raised them.


Accidental deaths robbed several families of their loved ones. Another elder woman, Elder 1, told how she lost her son in 1992:
   ...going north they went and um, he passed a car and then just then
   a car came over the hill and the car didn't pull in so he pulled
   off the road and went through the fence and then the car flipped
   over and then it just started burning. But they got him out and
   they got his wife out and my nephew out. They got them all out. But
   he was ... they rolled about ... twice and he had a cast on his
   left [leg] and he was driving and here his foot got caught under
   ... the brake and the car rolled on him. He had weeds in his hair
   and had, they all had long hair, and he had weeds in his hair and,
   and his sisters had a hard time taking the weeds out. Then he had a
   little girl four years old and I was babysitting her here because
   they went to that rodeo and she didn't want to go she wanted to
   stay with me.


In addition to the accidental deaths, American Indians experience high rates of health disparities including heart disease, diabetes, and cancer. The shorter life expectancies leave families without their loved ones. Elder 10 said, "My oldest son had a heart attack and died. He had a massive heart attack that's the worst--one of the worst things that happened this last year but it was it was the worst time of the year I think."

Experiences of health-related deaths and accidents robbed the elders of their children. These elders shared narratives related to the loss of their children, an experience that was prevalent among the elders in this study. These losses mirror the losses of their spouses, which were also often due to health-related issues.

Loss of a Spouse

Many of the elder women in the study are widows. One of the elder men, Elder 21, explains the situation of having women on the reservation assume the responsibilities of raising children and becoming the backbone of the family and the community:

Elder: Yeah, yeah. There's a lot of widows around, you pr'y know that ... yeah. There are lots of them [clears throat]. Two of my sisters are widows and they were young widows--forties. My mom was about fifty when my dad died. They weren't together, but they were still married. Life expectancy of men is really short.

Interviewer: Why is that?

Elder: A lot of it has to do with diet. A lot of it has to do with depression, depression and alcoholism. Along with depression you are going to talk about diabetes and heart disease. Depression is brought on by loss of self-worth-- early when they are young.

Interviewer: Are we talking about boys?

Elder: Right now yes, but it does work with women too because they become the bread winners early. They are the backbone of the family and the breadwinners and yet nobody really recognizes that.

Many of the women in the study had a similar experience of becoming the backbone for their family from their own children continuing through to their grandchildren and great-grandchildren. One elder was widowed when she was forty-three years old, a year after she had had the last of her ten kids. She narrates:
   So and then [her husband's name] died what? In '78 so then after
   that I just had to raise all those, those little ones I had by
   myself. I was scared to death at first because I never did have to
   worry about a bill because he figured everything, paid everything
   and when I had to, oooh, my god, I thought I was going to die.
   "[Her oldest daughter], you have to teach me how."

   She said, "Mom you can do it. Just make up your mind."

   "I can't. I can't. I can't." Oooh that was ... then I come up here
   and I tried got into the bank and boy and I'd keep track of every
   little thing. "Why do you do that?" So I said then I go back and
   make sure that I don't. I don't want to make [mistakes].


The widows and other women who were divorced bore the entire burden of raising a family and attending to the details alone. The support of the adult children was essential for this transition because the elder had to deal with a new baby and the loss of her husband.

Grief over a lost child and heart disease robbed an elder woman, Elder 22, of her husband. They lost their child and then this loss was compounded by the loss of her spouse a very short time later:

Elder: He had high blood pressure and diabetes, heart trouble; he had seven bypasses on the heart right after our son died.

Interviewer: What do you think caused that?

Elder: They said stress. He didn't do; you are supposed to let the bereavement [of the son go] and he held it. He had two heart attacks. One on Thanksgiving, and my son died September 28, and October, November [she counts with her fingers on the table] and he was going to go hunt. We lived in housing at that time; after he retired, we lived in housing and that morning he said he was going to go hunt.'Tll be back about the time you'll be done cooking."

My mom was still alive then, and here I was cooking, and he picked up my nephew and I was sitting here cooking, and my nephew just ran in and he said, "Auntie [her name] you better get the ambulance."

I said, "What happened?"

"Uncle had a heart attack out there. He laid down for a while, and then he felt better and he came back in."

I said, "Where is he?"

"He's coming back in."

In November time, the snow is bad and here he come in, holding his mouth; he sat down and put his head back.

"Call the ambulance or somebody" and he said he was going to have another one and his leg just went down and his head went back. About that time, my oldest daughter called the ambulance and they came. At that time, we had a station wagon. We always had station wagons. So me and my oldest daughter followed him, and they went on Hisell Road and they got him, and just as they were going to put him on the stretcher on the ambulance, he had another one. So he had three--one out there, one in here, and one at the hospital. So they stabilized him so he laid over there until he got well and they scheduled him for open heart surgery; he had to have a seven bypass and after that he went down. He always provided for us and it was really hard. I looked to him for anything and geez and [inaudible] after he died. He died [date].

The women who were widowed simply rose to the responsibility of raising their children and finding ways to support themselves, with or without the assistance of their families. As a result, the weight of the child rearing fell on these women's shoulders and thus they were considered the backbone of Lakota culture and life. Handling losses and grief that piled up as they moved through their lives left the elder women not only to struggle economically in a resource-poor environment, but also to struggle with their emotions while continuing to raise children and grandchildren.

Losses in the Community

While this research was being conducted on the reservation, several incidents occurred in which young people were either injured or killed as a result of accidents. The reactions of the elders captured the way that they regarded each and every one of these children as their own, thereby escalating the emotional anguish they felt. When one woman, Elder 11, heard about a young man being run over in a community on the reservation seventy miles from where she was living, she shared the following with the author:
   There is a lot of concern going on in some kids, especially in
   Oglala, in daytime, a woman run over a boy just fourteen years old,
   daytime. She don't stop and check. She run over that boy, and
   second [came over the] hilltop and run over this boy, and third one
   come and he don't know so he run over [the boy as well]. Fourteen
   years old. And I was really angry when I heard about it. That first
   woman that was driving to Pine Ridge; she's not blind. She's not
   blind. How come she went and run over that fourteen years old boy
   walking along that road? That happened this winter. I'm going to
   dress warm and go to Oglala and I'm going to see that boy; I don't
   know, what's his name or whatever. My grandsons called from over
   there, "Grandma, they're doing ok, so you don't need to come. I
   know that you are angry, everybody's mad when these three cars run
   over him." It was daybreak and how come that middle-aged woman run
   over that boy walking in the road? I wonder how come she did that.
   She thinks she's well educated, holding that steering wheel.


This incident is significant in revealing the expansive boundaries of the mental well-being and consciousness of the elders. The elders care not only for their children, grandchildren, and great-grandchildren, but also for the children, grandchildren, and great-grandchildren of the entire reservation community as well as the community members who live in nearby off-reservation towns. The well-being of the younger generations weighs very heavily on the elders, who become upset and aggravated when these incidents occur. The elders discuss such incidents among themselves at the meal sites, at community events, and at other places where they congregate and run into each other. The elders also attend the funerals and wakes, supporting one another in their feelings of helplessness and loss. Due to its vast scope, this sense of collective responsibility and emotional care embedded within the elders is very different from what is found in non-Native communities. Communities on the reservation can be separated by as much as 100 miles; for instance, Rapid City is roughly 100 miles from the reservation. Yet the connections between the elders and the people on the reservation are so close that they care about and grieve a death that occurs 100 miles away. In the white world, the boundaries of collective responsibility and emotional care are much more narrowly drawn; they certainly do not extend to encompass all those living in such a wide range of settlements.

Discussion

As people age, they experience loss of their family members and friends in their network. As the narratives in this study reveal, for the Lakota elders the losses began when they were children with the deaths of their siblings and caregivers and then other losses began to accumulate as they moved through their life span. The elders experienced many losses as some were widowed at young ages and then lost children in accidental or health-related deaths. The elders were often left to raise their families and pick up the pieces for grandchildren who had lost their parents. The accumulation of this grief was revealed in the narratives as the elders cried and shared the many losses they had experienced. American Indians struggle with health disparities related to diabetes, heart disease, cancer, high suicide rates, and accidental death. These narratives uncover the experiences of the people who were affected by those statistics and the families that were left behind. The strength and resiliency of the elders are apparent; many rose to the challenge of raising children and coping with their grief in the reservation environment.

Implications for Best Practices

The findings from this study have a number of important implications for behavioral health practice with American Indian elders. First, the elders need relief from the grief that they have experienced and continue to experience as some have carried this grief for decades. When asked if they had utilized behavioral health services on the reservation, none of them had. A few used their traditional spirituality and leaders to work through their grief and bereavement. The efforts of the Indian Health Service and other programs and services that provide care to the elders need to direct recruitment efforts toward the older adult population. Many of them are raising grandchildren and will need support in their own grief and bereavement and they will need to develop skills to support loved ones with their loss. Given the high rates of suicide in American Indian youth, often when a death occurs in the community, the behavioral health programs provide support to those attending vigils, wakes, and funeral services, as well as support to youth in the schools. Attention to the elders in those communities is particularly important because of the many losses they have accumulated across their life spans.

Culturally tailored models for working through grief are important when working with the elders living in reservation communities. The interventions for American Indians often utilize groups, which are appealing to the communal nature of reservation communities and culture. A Lakota Grief Experience Questionnaire and psychoeducational intervention for addressing the historical trauma experienced by Lakota people as a result of massacres and boarding school experiences has been developed by Maria Yellow Horse Brave Heart. This intervention includes education on trauma, group exercises, and a traditional ceremony. Gone (2009) reported on the healing lodge treatment program for substance abuse that was used and culturally tailored to a Canadian Indian community and noted that the therapeutic priority is on healing more than treatment. The outpatient treatment program offered lectures, individual counseling, community outreach, and cultural activities. This more holistic view of healing includes physical, mental, emotional, and spiritual aspects. These models offer potential for working with older American Indians coping with present-day grief and bereavement. Clinicians need to be aware of best practices with older adults and working with the many layers of grief. The narratives underscore the need for practitioners to have insights into working with the sheer number of losses that are so commonplace for American Indians living on this reservation. Also, all of the elders in the study experienced at least one chronic disease. As they interact with health practitioners regarding their physical health issues, it will be important to assess their behavioral and emotional health because grief and loss often result in stresses on physical health.

Conclusion

Lakota elders living on the reservation in South Dakota experience many losses over their life span. These losses begin in their early childhood and continue through to older adulthood. Although these elders are resilient and cope with the grief and loss, several have carried the losses of their primary caregivers for decades. Behavioral health resources focused on outreach and recruitment of older American Indians is imperative. Culturally tailored interventions to alleviate the strain of these losses are sorely needed.

Mary Kate Dennis, PhD, is assistant professor at the School of Social Welfare, University of Kansas, Lawrence, KS.

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Publication:Best Practices in Mental Health
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Date:Oct 1, 2014
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