Addressing historical trauma
Other psychologists are finding ways to treat populations that
are at even higher risk than the rest of rural America.
American Indians are one group at especially high risk.
According to the CDC, American Indians and Alaska Natives
ages 15 to 34 have a suicide rate two-and-a-half times higher
than the national average for adolescents and young adults, for
Historical trauma is a major factor, says Jacque Gray, PhD,
past president of the Society of Indian Psychologists and
another member of APA’s Committee on Rural Health.
“The loss of land, culture, identity, all those things have
really taken a toll and haven’t been grieved,” says Gray, associate
director of the Center for Rural Health at the University of
The history of removing American Indian children from
their parents and placing them in far-away boarding schools
also contributes to suicide, says Gray. “That whole generation
didn’t learn how to parent,” she says. “What they learned was
how they were treated in boarding schools, so substance abuse,
sexual abuse, child abuse, physical abuse, emotional abuse have
just repeated generation after generation.”
Add to all that poverty, lack of insurance and provider and
resource shortages so severe that clinics are forced to turn away
suicidal clients. And many suicide prevention efforts aren’t well-
suited to American Indians, says Gray.
What often happens is that people try to apply practices that
work in other contexts to Indian country, says Gray. “It doesn’t
work,” she says.
Fortunately, she says, practitioners in Indian country have
developed promising practices. One is using traditional cultural
ceremonies, such as sweat lodges, purifications, rites of passage,
dancing and storytelling. These traditions can help individuals
build a stronger sense of both individual and cultural identity
and connect them to their communities — sources of strength
that can help reduce suicide risk, says Gray.
Another promising practice is to broaden the focus
beyond the individual at risk of suicide. One suicide hotline
in Indian country gets entire families involved in phone calls,
for example. Staff will also go out to communities rather than
expecting individuals and families to come to them, a trip that
can be more than 100 miles. Also important is training native
psychologists, the mission of Gray’s own Health Resources and
Services Administration-funded Seven Generations Center of
Excellence in Native Behavioral Health.
Bringing care to vets
Rural veterans are another group at heightened risk of suicide.
Forty-four percent of vets returning from Iraq and
Afghanistan come home to rural ZIP codes, says psychologist
Mark F. Ward, PhD, director of the Oregon Rural Mental
Health Team at the Portland Veterans Affairs Medical Center in
But while the VA has 160-odd medical centers and about
1,000 community-based outpatient clinics, many vets must still
travel long distances to get care. Most VA clinics have very small
mental health teams if they offer any mental health services at
all; community-based mental health centers may not have the
expertise to treat post-traumatic stress disorder, military sexual
trauma and other suicide risk factors common among vets.
Plus, the stigma about mental health disorders and treatment is
especially strong in the military.
“We often see them two years after they’re back, when
they’ve lost their jobs, their [spouses] have kicked them out and
now they’re in real trouble,” says Ward. “We’re trying to head off
all those problems.”
To achieve that goal, Ward and colleagues established the
Oregon Rural Mental Health Team in 2009 to provide high-
quality mental health services to even the most isolated veterans
in the state. The solution? Technology.
Mental health providers based in Portland connect with
veterans in the VA’s community-based outpatient clinics, using
webcams and videoconferencing units that work like Skype
but with heightened security. Because many vets live far from
clinics, the team can also mail webcams to veterans for use
in their own homes — the first time the VA has granted such
permission, says Ward, adding that the team will soon start
providing tablets and notebooks to veterans who lack access to
high-speed Internet but do have cellular coverage.
As a result, the state’s rural veterans can now receive
medication evaluation and management, individual and group
psychotherapy, couples counseling and other services no matter
where they are. And, says Ward, nobody has to know they’re
seeking help because it can happen in their own living rooms.
“A variety of mental health services can now be piped
into rural, isolated communities to provide care to vets who
would have never received care without it,” says Ward, adding
that there are practical as well as psychological ramifications.
“In 2013, we saved veterans 826,290 miles — the equivalent
of three-and-a-half trips to the moon — and an estimated
Preventing access to lethal means
In addition to focusing on what’s going on in suicidal clients’
heads, psychologists must also focus on what’s going on in their
environments, say Hirsch and others.
Take firearms, for example. While firearms are a common
suicide method across the country, says Hirsch, the rate of
suicide by firearms is much higher in rural areas.
“Rural individuals often grow up around guns and have
them in their homes,” he says, explaining that rural residents
often keep guns for hunting and agricultural needs, recreation
or simply because there’s a culture of guns in their areas. “There
have not been any efforts or studies to examine acceptable ways
of means restriction in these communities, many of which
have a pro-firearm stance as well as some mistrust of external