Historical trauma and oppression: Associations with internalizing outcomes among American Indian adults with type 2 diabetes

Abstract

American Indian (AI) people experience disproportionate exposure to stressors and health inequities, including type 2 diabetes (T2D) and mental health problems. There is increasing interest in how historical trauma and ongoing experiences of discrimination and marginalization (i.e., historical oppression) interact to influence AI health. The purpose of this study is to examine the relationships between historically traumatic experiences (i.e., boarding schools, relocation programs, and foster care), current reports of historical cultural loss, microaggressions, and their relationship to internalizing symptoms among AI adults living with T2D. This community-based participatory research study with five AI tribal communities includes data from 192 AI adults with T2D recruited from tribal clinics. Results from structural equation modeling revealed that personal experiences in foster care and ancestral experiences in boarding schools and/or relocation were associated with increased reports of historical loss, and indirectly associated with internalizing symptoms through racial microaggressions and historical losses. The findings highlight the importance of considering multiple dimensions of historical trauma and oppression in empirical and practice-based assessments of mental health problems.

Keywords

American Indian boarding school foster care historical trauma indigenous microaggressions

American Indians (AIs) are one of the fastest-growing and most diverse racial/ethnic groups in the United States (U.S.) (US Census Bureau, 2012) across 574 federally recognized tribes and 100 state-recognized tribes (Bureau of Indian Affairs; https://www.bia.gov/bia). AIs experience some of the worst physical and mental health inequities in the U.S., including high rates of suicide, substance use, and chronic diseases including type 2 diabetes (T2D; Indian Health Service, 2019). Social determinants contributing to the poor health status of AIs include differential rates of poverty, lack of equal access to education, and inadequate housing (Indian Health Service, 2019). Exposure to historical and contemporary stressors and the cumulative effects of colonization and its associated policies are implicated as root determinants of health inequities for AIs (Bombay et al., 2014b; King et al., 2009; Walls & Whitbeck, 2012a). Relatedly, AIs experience the highest rates of discrimination (American Psychological Association, 2016). This is particularly true in the case of T2D, a condition etiologically linked to and complicated by stress and trauma exposure (Jian et al., 2008; Surwit et al., 1992; Walders-Abramson et al., 2014). Further, profound issues of social injustice underlie T2D as a modern epidemic for AIs. For example, disruption of traditional family and sustenance systems contributes to more sedentary lifestyles and reliance on commodity food programs (Satterfield et al., 2016), all of which increase the risk of T2D. Much research has yet to be done to understand the complexity of historical and contemporary marginalization and how they influence the mental and physical health of AIs.

Historical trauma

There is ongoing scholarly attention to the potential long-term consequences of historically traumatic events experienced by AIs (Evans-Campbell, 2008; Gone, 2009; Whitbeck et al., 2004). Historical trauma (HT) is characterized by a series of accumulating, purposefully imposed traumas experienced over time by a group of people; these experiences are carried forward to influence future generations (Braveheart, 1998; Walters et al., 2011). Empirically assessing the impacts of HT is complex, partly because the social experiences of oppressed groups are diverse (Kirmayer et al., 2014), and because there are myriad potential mechanisms of HT impact and outcomes (Walters et al., 2011).

The study of HT among AIs first emerged in the literature during the mid-1990s (Gone, 2013; Maxwell, 2014), and was described as a complex form of Posttraumatic Stress Disorder (PTSD) from colonization (BraveHeart, 1993; Duran & Duran, 1995). Initially, the term encompassed the preexisting constructs of historical oppression and psychological trauma (Gone, 2013). More recently, research and grassroots initiatives to address and understand HT throughout Indian Country have significantly increased. HT has been discussed interchangeably with other terms including soul wound, collective unresolved grief, intergeneration trauma, and transgenerational trauma (Palacios & Portillo, 2009), and has been described as an etiological agent to distress (Walters et al., 2011), a trauma response (Braveheart, 1998), a mechanism, and a historical stressor interacting with other contemporary stressors (Whitbeck et al., 2004). Others have proposed that HT is best conceptualized as a form of public narrative (Mohatt et al., 2014).

The transmission of HT is thought to be varied and is likely multifactorial. Research on HT includes an examination of the impacts of boarding schools (Bombay et al., 2011; Elias et al., 2012), relocation policies (Walls & Whitbeck, 2012b), and historical cultural losses (Whitbeck et al., 2004), all of which impact individuals and communities. Boarding schools, relocation programs, and foster care systems are among the tools of colonization that separate AIs from their families and culture. Historical cultural losses are a contemporary source of distress resulting from those historical events and processes (Walls & Whitbeck, 2012a). Overall, despite growing research on HT, the concept is still being used to describe a variety of complex phenomena and outcomes requiring the further need for research and scholarship.

Dimensions of historical trauma and associations with AI health

This article focuses on four dimensions of HT discussed in the literature: (1) boarding/residential schools, (2) relocation programs, (3) foster care systems, and (4) historical cultural losses. Below, we briefly review these four indicators and provide evidence of their associations with Indigenous health outcomes. Later, we link these concepts with a more recent discussion of historical oppression; an expansion of HT that includes consideration of contemporary stressors and systems of marginalization (Burnette, 2015).

In the U.S., AI communities have been subjected to governmental policies that were aimed at their assimilation into western culture. These policies include boarding schools established largely in the late 19th through mid-20th centuries with a mission to “Kill the Indian, Save the Man” (Lomawaima & Ostler, 2018). AI children were forcibly removed from their homes and forbidden to use their traditional language or to practice their spiritual beliefs in attempts to assimilate them into European American culture (Adams, 1995). Children were deprived of care, protection, and exposure to traditional child-rearing practices. Many were subjected to emotional, physical, and sexual abuse. While some children survived, numerous died from disease, malnutrition, and harsh conditions. Boarding schools have had devastating consequences for Indigenous families and communities as a result of family separation and lack of positive parenting role models that continue to negatively affect AI families today (Braveheart, 2003; Irwin and Roll, 1995; Noriega, 1992). Recent recovery of ancestral remains including mass burials of Indigenous children on residential school lands further represents a significant trauma for contemporary Indigenous families (Austen & Bilefsky, 2021).

Relocation of AIs to urban areas started in the U.S. in 1948. These legislatively sponsored policies coerced AIs to live and work as assimilated citizens where they faced discrimination in housing and employment (Braveheart, 1998). During the 1950s to 1970s, more than 100,000 AIs were sent to major urban areas throughout the U.S. (Barse, 1994), often separated from their families and isolated from their culture. Both boarding school and relocation-era policies have been empirically linked to poorer health, including increased substance use and suicidality, not only for survivors but also for their offspring and subsequent generations (Bombay et al., 2011; Elias et al., 2012; Walls & Whitbeck, 2012b).

Although AI children and their families are overrepresented in the child welfare and foster care systems, there is a lack of AI representation in child welfare research (Landers & Danes, 2016). High rates of removal of AI children led to the enactment of the Indian Child Welfare Act of 1978. In the 20 years prior, the Indian Adoption Project was developed between the Bureau of Indian Affairs (BIA) and the Child Welfare League of America which promoted the adoption of AI children by non-Native families (Mannes, 1995). Children were removed from their homes by non-AI social workers and placed for adoption in cities far from their families (Mannes, 1995) for reasons such as poverty and lack of understanding of the Indigenous family structure (Mannes, 1995). For many tribes, it was common for children to be raised with extended families (Jones et al., 2008). As such, many AI families were judged unfit and were accused of neglect or emotional mistreatment or had their children taken away for being cared for by an extended relative (Jones et al., 2008). Other reasons for the removal of AI children included concerns for the caregivers’ mental health. Of the parents who were deemed mentally unfit to provide for their children, less than 20% were referred to mental health services and even fewer received care (Libby, 2007). By 1978, as many as 35% of AI children were removed from their homes and placed in substitute care (Mannes, 1995), 85% of whom were placed in non-AI homes (Jones et al., 2008). The initial research suggests that the negative impacts of AIs in foster care have lifelong psychological impacts (Bombay et al., 2011). From forced relocations to boarding schools to child welfare practices, AI families are significantly impacted by systemic separation.

Historical loss has been conceptualized and measured to assess the frequency with which AIs experience thoughts of cultural losses (e.g., loss of land, culture, spiritual ways, etc.) due to colonization (Whitbeck et al., 2004). Historical cultural losses have been associated with distressing feelings, sadness, depression, anger, intrusive thoughts, discomfort, shame, fear, and distrust of Caucasian people (Whitbeck et al., 2004). One study found that up to one-third of AI adults think about historical losses daily or even several times a day and that these thoughts are associated with increased alcohol use disorder and symptoms of internalization (Whitbeck et al., 2004).

Historical oppression and discrimination

Descendants of survivors of historically traumatic policies may have worse health outcomes and be more vulnerable to contemporary stress resulting in higher levels of depression, suicidal ideation and attempts, and PTSD symptoms (BraveHeart, 2003, McQuiad et al., 2017). This highlights a critical point regarding HT: many of the events endured by AIs originated in the past, but its effects and systems of oppression rooted in history persist to the present day. The difficult road to recovery from historically traumatic events is compounded by the fact that AIs continue to experience ongoing adversity. The term Historical Oppression has been used to describe ongoing marginalization that is chronic, pervasive, and normalized and internalized into the daily lives of many AIs (Burnette, 2015), including experiencing discrimination and ongoing marginalization.

There is growing literature that ties the stress induced by discrimination to poorer physical and mental health (Williams-Morris, 2000). At least seven out of 10 AI adults report experiencing everyday discrimination, and more than half feel that it has contributed to making their life more difficult and 36% attribute this difference to their race (APA, 2016). Further, discrimination is associated with depressive symptoms among AI adults (Whitbeck et al., 2002) and when perceived through a lens of historical loss may trigger negative emotions among some AIs (Whitbeck et al., 2001). In modern contexts, discrimination often takes the form of microaggressions, the subtle (often unconscious) daily indignities experienced based on membership in an oppressed or marginalized group (Sue, 2010). There is a growing body of literature that examines the impact of microaggressions on the health of AIs and has shown them to be associated with depressive symptoms (Sittner et al., 2018; Walls et al., 2015), the prevalence of hospitalizations, cigarette use in adolescents (Dickerson et al., 2019), and overall worse health outcomes (Sittner et al., 2018).

The current study

The purpose of this study is to assess the relations between historically traumatic events (parent and/or grandparent boarding school attendance and relocation participation, and participant foster care placement), thoughts of historical cultural losses, perceived discrimination, and internalizing symptoms among a sample of AI adults living with T2D. Figure 1 displays the conceptual model linking these constructs together. Based on extant research, we posit that historically traumatic events (Hypothesis 1), thoughts of historical cultural losses (Hypothesis 2), and perceived discrimination (Hypothesis 3) will be positively associated with internalizing symptoms.

Figure 1.
Conceptual Model. Note: Solid line = direct effect; dashed line = indirect effect.

The anticipated associations between the constructs of historical trauma, historical cultural losses, and perceived discrimination are based on the concept of historical oppression wherein HT undergirds contemporary experiences of marginalization and stress exposure (Burnette & Figley, 2016). In this study, we conceptualize historical cultural losses and perceived discrimination as stressors (Walls & Whitbeck, 2012a). Close familial and direct experiences with these historically traumatic events are associated with secondary stressors that knit together distal experiences and contemporary health outcomes (Bombay et al., 2014b). For example, children of parents who participated in a government relocation reported higher rates of parental and personal alcohol use problems (Walls & Whitbeck, 2012b). These adverse experiences in turn partially linked familial relocation experiences with externalizing and internalizing symptoms among a third generation of youth. Likewise, Bombay et al. (2011) found that second-generation survivors of Indian Residential Schools in Canada experienced higher rates of adverse childhood experiences and discrimination in adulthood. The association between perceived discrimination and depressive symptoms was also greater for individuals whose parents attended an Indian Residential School compared to those whose parents did not. Relatedly, Matheson et al. (2019) found that the frequency of negative communications around parental Indian Residential School attendance was associated with increased perceptions of discrimination among children. Further, the inability or reluctance of parents to directly speak about these experiences was associated with a greater sense of internalized stigma and shame among their offspring, and greater attunement to both external and internal (e.g., lateral violence) forms of discrimination.

Following the left side of Figure 1, we posit that close familial boarding school and relocation participation, along with foster care placement (i.e., Historical Trauma), will be positively associated with thoughts of historical cultural losses (Hypothesis 4). People who experience these historically traumatic events are likely more attuned to these consequences for themselves and their families through storytelling and/or direct experience. Because of this direct salience, we would also expect that they are more attuned to the broader impacts of these historically traumatic events on all Indigenous peoples, compared to those with more distant familial historically traumatic experiences.

In the center of the conceptual framework displayed in Figure 1, we link historically traumatic events and perceptions of cultural loss to microaggressions. The sequalae associated with personal and ancestral experiences of HT along with enduring thoughts of historical cultural losses may be associated with deserved distrust and greater attunement to discriminatory behaviors and verbal cues from others (Matheson et al., 2019). In this sense, we posit a direct association from historical trauma and cultural losses to microaggressions (Hypothesis 5).

Based on the concept of historical oppression (see above), perceived discrimination and contemporary thoughts of cultural loss are anticipated to link the distal and proximal manifestations of HT with internalizing symptoms (Hypothesis 6). That is, we anticipate thoughts of historical cultural losses and discrimination will serve as mediating pathways between distal markers of HT and internalizing symptoms. Bombay et al. (2011) found that discrimination mediated the relationship between parental Indian Residential School attendance and internalizing symptoms among Canadian First Nations adults. We expand upon this research by including additional types of HT (i.e., familial relocation participation and foster care placement) and participants from both Canada and the U.S. In addition, our focus on a sample of adults living with T2D is particularly significant. Indigenous peoples in the midwestern U.S. experience disproportionate rates of T2D, and stress/trauma is a known etiological agent of diabetes across cultures (Walls et al., 2017). Furthermore, comorbid mental health problems among individuals with diabetes increase the risk of diabetes complications and mortality (Walls et al., 2017).

Methods

Procedure and sample

The Maawaji’ idi-oog Mino-ayaawin (Gathering for Health) project is a community-based participatory research (CBPR) collaboration between researchers and five AI (Ojibwe) communities. The overarching objective of the study was to understand stressors and their impact on T2D-related outcomes. Tribal resolutions supporting the project were granted by all five tribal nation governments. Community Research Councils (CRCs) from each tribe and members of the university research team collaboratively developed and implemented study protocols, and participated in data collection, interpretation, and dissemination. Project methodology and human subjects approval was granted by the University IRB and the IHS National IRB. Staff at each IHS clinic site generated simple random samples for study recruitment from patient records. Inclusion criteria were a diagnosis of T2D, age 18 years or older, and self-identified as AI/AN. A total of 194 participants enrolled in the study, representing a recruitment rate of 67%. Participants were interviewed four times in six-month intervals starting in 2013 and ending in 2015. We used data from baseline (n = 192) and the second wave of assessment (n = 166). Participants received a US$50 incentive and a small, culturally meaningful gift for their participation. Additional details about study design have been published elsewhere (Walls et al., 2017)

Measures

Historical trauma. Participants were asked at baseline if they have ever been placed in foster care. Response options were coded as (0) no and (1) yes. Parent and grandparent boarding school attendance was examined through two separate questions asking respondents whether their parents or grandparents ever attended a boarding or residential school. Respondents who responded no to both questions were coded as zero, and those who reported yes to one or both questions were coded as one. Parent or grandparent relocation participation was assessed and coded in a similar fashion with two separate questions on whether a parent or grandparent had participated in a government relocation program.

Historical cultural loss. Historical loss was assessed at baseline of the study with an adapted version of the Historical Loss Scale (Whitbeck et al., 2004). Respondents were asked how often they think of 13 historical losses and trauma (e.g., loss of our land, destruction of our culture). Response options range from (0) never to (5) several times a day. A principal-axis factor analysis indicated that there are three dimensions to the historical loss scale (see also Armenta et al., 2016 for measurement properties). The items and the factors are shown in Table 1. To reduce the complexity of the proposed latent variable model, items within each dimension were averaged to create three separate item parcels.

Table 1.
Items Used in Historical Cultural Loss and Microaggression Measures.

Historical cultural loss

Factor 1

Taking of our land

Separation of family ties because of boarding or residential schools

Removal of families from the reservation due to government relocation

Loss of trust in whites from broken treaties

Factor 2

Fewer people using traditional language

Attacks on traditional spiritual ways

Factor 3

Destruction of our culture

Loss of respect for elders by our children and grandchildren

Loss of respect by our children for traditional ways

Damages to our sense of community

Destruction or damage of traditional foods

Taking of family members by non-Native foster care or adoption placements

Destruction of natural resources and beauty due to pollution, mining, and other industries

Microaggressions

Being called something racist, such as Chief, Wahoo, Squaw, Indian Giver, Savage, or Pocahontas?

Feeling like Native people are “invisible” to the rest of society?

Hearing from non-Natives how surprisingly well-read or smart you are?

Feeling stereotyped by non-Native persons?

Seeing portrayals of Native people in TV, movies, or as sports mascots?

Someone suspecting you of doing something wrong because you are Native, for example being followed in stores or hassled by police?

People acting as if they are afraid of you because you are Native?

People accusing you of being oversensitive when you try to discuss race issues or racism.

Feeling like you are treated differently because of your race or ethnicity?

Microaggressions. Racial microaggressions at Wave 2 of the study were assessed through 11 items asking respondents whether they have experienced various forms of microaggressions and whether it had bothered them in the past six months (i.e., since their last interview; Chae and Walters, 2009; Table 1). Response options were (0) this never happened, (1) this happened but it didn't bother me, and (2) this happened and I was bothered by it. To reduce the number of items used in the formation of a latent construct, three item parcels were derived. Little and colleagues (Little et al., 2002) highlight multiple statistical and analytic advantages of item-parceling, particularly when the focus is on the relations between constructs and not on the measurement properties of latent variables. On the measurement side, item parcels have greater reliability, greater communality, and a decreased likelihood of distributional violations. On the modeling side, item parcels decrease the number of parameters in the model, reduce the likelihood of correlated residuals and dual-factor loadings, and reduce sources of sampling error. For unidimensional items, a balanced approach is used to assign items into three parcels.

A principal-axis factor analysis was conducted, which indicated that two of the items had low factor loadings (see also Sittner et al., 2018). Unlike the historical cultural loss measure, all other items loaded onto one factor. A balanced approach was used such that the item with the highest factor loading was paired with the item with the lowest factor loading and included in the first item parcel. The item with the second highest factor loading was paired with the item with the second lowest factor loading and placed in the second item parcel. The item with the third highest factor loading was paired with the item with the third lowest factor loading and placed in the third item parcel. The item with the fourth highest factor loading was placed in the third item parcel, the item with the fifth highest factor loading was placed in the second item parcel, and the item with the sixth lowest factor loading was placed in the first item parcel.

Internalizing symptoms. Internalizing symptoms include conventional measures of depressive and anxiety symptoms, and previous studies with Indigenous people have characterized internalizing disorders in terms of multidimensional loneliness (O’Nell, 1998). Three measures of internalizing symptoms were examined at Wave 2 of the study. Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-9; Spitzer et al., 1999), which asks participants how often in the past week they have been bothered by various problems (e.g., feeling tired or having little energy, feeling down, depressed, and hopeless). Response options range from (0) not at all to (3) every day. Items were summed to create a scale of depressive symptoms. Anxiety symptoms were assessed with the General Anxiety Disorder 7-item scale (GAD-7; Spitzer et al., 2006), which asks participants how often in the past two weeks they have been bothered by various problems (e.g., feeling nervous, anxious, or on edge, worrying too much about different things). Response options range from (0) not at all to (3) nearly every day. Items were summed to create an index of anxiety symptoms. Feelings of loneliness were assessed with an adapted six-item version of the UCLA Loneliness Scale (Russell et al., 1980). Respondents were asked how often each item describes them (e.g., I have nobody to talk to, I feel completely alone). Response options range from (0) never to (3) always. Items were summed to create a scale of loneliness.

Demographic controls. Five demographic controls were included in the analyses, including sex (0 = male; 1 = female), years of age (continuous), and whether participants resided on or off reservation land (0 = resides off reservation land; 1 = resides on reservation land). Per capita family income was assessed by asking participants to report their total annual combined household income from all sources. Response options were assessed in US$5,000 increments ranging from (0) less than US$5,000 to (10) US$70,000 or more. The mid-point of each category was taken and divided by the number of people residing in the home (further divided by 1,000 to reduce the scaling). The number of years living with type 2 diabetes was assessed through one question, which asked how many months ago participants were diagnosed with type 2 diabetes (responses divided by 12).

Analytic strategy

To test the proposed model, structural equation modeling was used in Mplus Version 8 (Muthen & Muthen, 1998–2017). Missing data were handled using robust maximum likelihood estimation. An attrition analysis comparing those who dropped out at Wave 2 of the study showed that males had higher odds of attrition than females (44% in Wave 1 and 39% in Wave 2), and participants who had been diagnosed with T2D longer ago had higher odds of attrition (Wave 1 sample = 1.58 years prior to baseline interview; Wave 2 sample = 1.45 years prior to baseline interview). Model fit was assessed using chi-square, comparative fit index (CFI), Tucker Lewis index (TLI), root mean squared error of approximation (RMSEA), and standardized root mean squared residual (SRMR). A non-significant chi-square value, CFI and TLI values greater than 0.95, RMSEA values below 0.06, and SRMR values below 0.08, with converging evidence across fit indices suggest good model fit (Hu & Bentler, 1999). Internalizing symptoms, microaggressions, and historical loss were specified as latent variables. For internalizing symptoms, PHQ-9, GAD-7, and loneliness scale items were included, with factor loading for PHQ-9 fixed to one to set the latent variable scaling. For microaggressions and historical loss, one of the factor loadings was fixed to one to set the latent variable scale.

Results

Table 2 displays the descriptive statistics for all items included in the analyses. Over half of the baseline sample was female (56%), and the average age was 46.32 years (S.D. 12.51). A large majority of participants reside on reservation land (79%). The average per capita family income of the baseline sample is US$9,770 (S.D. US$8,880). On average, participants were first diagnosed with type 2 diabetes 1.58 years prior to being interviewed (S.D. 1.48 years). The average PHQ-9 score was 4.75 (S.D. 4.86), and the average GAD-7 score was 4.27 (S.D. 4.85), both of which correspond with low/mild symptom severity (Spitzer et al., 1999, 2006). Under one-fifth of the sample scored a 10 or higher on both instruments, which is indicative of a likely major depressive or generalized anxiety disorder (16.3% and 15.1%, respectively).

Table 2.
Descriptive Statistics (N = 192).

Mean S.D. Alpha Proportion missing

Female 0.56 0.00

Age 46.32 12.51 0.00

Per capita family income (per US$1,000) 9.77 8.88 0.01

Resides on reservation land 0.79 0.00

Years with type 2 diabetes 1.58 1.48 0.02

Foster care 0.23 0.02

Parent/grandparent boarding school 0.62 0.10

Parent/grandparent relocation 0.28 0.02

Historical loss factor 1 1.38 1.18 0.87 0.01

Historical loss factor 2 2.10 1.25 0.92 0.01

Historical loss factor 3 1.92 1.30 0.82 0.01

Microaggressions parcel 1 1.55 1.50 0.83 0.15

Microaggressions parcel 2 2.46 1.92 0.83 0.15

Microaggressions parcel 3 1.91 1.78 0.83 0.15

PHQ-9 depressive symptoms 4.75 4.86 0.85 0.15

GAD-7 anxiety symptoms 4.27 4.85 0.92 0.15

Loneliness 3.99 4.07 0.87 0.15

Approximately one-fourth of the participants were ever placed in foster care (23%). Nearly two-thirds (62%) of participants had a parent and/or grandparent who had attended a boarding school. Just over one-quarter (28%) of respondents had a parent and/or grandparent who had participated in a government relocation. The proportion of participants whose parents and/or grandparents attended a boarding school or participated in a government relocation were similar (and non-significant) across foster care placement status. There was, however, modest overlap between parent and/or grandparent boarding school attendance and parent and/or grandparent participation in government relocation. Among participants who had a parent and/or grandparent who had attended a boarding school, 80.8% had a parent and/or grandparent who had participated in government relocation, compared to 54.4% who did not have a parent and/or grandparent who had attended boarding school.

Table 3 and Figure 2 present the results of the SEM model. The proposed structural equation showed acceptable model fit (Chi-square = 120.44(72), p < 0.05; RMSEA = 0.06; CFI = 0.94; SRMR = 0.05). Two out of the three historical trauma variables were associated with thoughts of historical loss. Participants who had been placed in foster care reported thinking of historical losses more than participants who had never been in foster care (β = 0.13, p < 0.05). In addition, participants whose parents and/or grandparents had attended a boarding school reporting thinking of historical losses more than participants without ancestral boarding school experiences (β = 0.38, p < 0.01). Parent and/or grandparent relocation participation was not significantly associated with thinking about historical losses. Of the five control variables, only income was marginally associated with thinking about historical losses (β = −0.02, p = 0.054).

Figure 2.
Standardized SEM Coefficients (see also Table 2). Note: Only significant coefficients are shown. Model Fit: χ² = 120.44(72), p = 0.0003; RMSEA = 0.06; CFI = 0.94; TLI = 0.91; SRMR = 0.05.

Table 3.
Structural Equation Model Path Coefficients and Confidence Intervals. See also Figure 2 (N = 192).

Historical loss (W1) Microaggressions (W2) Internalizing symptoms (W2)

b [95% CI] β b [95% CI] β b [95% CI] β

Foster care 0.30* [0.03, 0.57] 0.13 −0.12 [−0.52, 0.29] −0.05 0.68 [−1.15, 2.52] 0.07

Parent/grandparent boarding school 0.74** [0.43, 1.06] 0.38 0.28 [−0.13, 0.69] 0.14 0.30 [−1.16, 1.75] 0.03

Parent/grandparent relocation 0.26 [−0.06, 0.58] 0.12 0.37⁺ [−0.03, 0.77] 0.17 −0.73 [−2.29, 0.85] −0.07

Historical loss (W1) 0.26* [0.02, 0.51] 0.25 −0.11 [−0.94, 0.71] −0.03

Microaggressions (W2) 1.52 [0.59, 2.44] 0.34

Female −0.09 [−0.36, 0.17] −0.05 −0.01 [−0.32, 0.31] −0.00 2.08 [0.62, 3.53] 0.24

Age 0.07 [−0.01, 0.02] 0.09 −0.00 [−0.02, 0.02] −0.02 −0.03 [−0.10, 0.02] −0.11

Per capita family income −0.01⁺ [−0.03, 0.00] −0.02 0.00 [−0.02, 0.02] 0.03 −0.08* [−0.15. −0.01] −0.16

On reservation −0.06 [−0.44, 0.32] −0.03 0.14 [−0.23, 0.50] 0.06 −0.29 [−1.83, 1.24] −0.03

Years with type 2 diabetes −0.06 [−0.15, 0.03] −0.01 0.00 [−0.11, 0.11] 0.01 0.17 [−0.49 0.84] 0.06

Note. W1: Wave 1; W2: Wave 2; CI: Confidence Interval.⁺p < .10; *p < .05; **p < .01.

Participants whose parents and/or grandparents had ever participated in a relocation program had higher experiences of recent microaggressions compared to participants whose parents and/or grandparents did not experience forced relocation; this effect was marginally statistically significant (β = 0.17, p < 0.071). Thoughts of historical losses were positively associated with recent experiences of microaggressions (β = 0.25, p < 0.05). None of the five control variables were associated with recent experiences of microaggressions.

None of the three historical trauma measures were directly associated with internalizing symptoms, nor were thoughts of historical losses. Recent experiences of microaggressions were positively associated with internalizing symptoms (β = 0.34, p < 0.01). In addition, females had higher levels of internalizing symptoms compared to males (β = 0.24, p < 0.01), and per capita family income was negatively associated with internalizing symptoms (β = −0.08, p < 0.05). No other demographic variables were associated with internalizing symptoms.

The significance of the indirect effects was assessed using 95% bias corrected bootstrapped confidence intervals using 5,000 bootstrap resamples (Shrout & Bolger, 2002). The indirect effect from foster care to internalizing symptoms through thoughts of historical losses and recent experiences with microaggressions was significant (b = 0.12, 95% CI = 0.01, 0.46). The positive coefficient indicates that participants who were ever placed in foster care have a higher level of internalizing symptoms through increased thoughts of historical losses leading to more frequent recent experiences of racial microaggressions, compared to those who were never placed in foster care. The indirect effect from parent and/or grandparent boarding school attendance was also significant (b = 0.30; 95% CI = 0.06, 0.85). The positive coefficient indicates that parent and/or grandparent boarding school attendance increases current internalizing symptoms through increased thoughts of historical losses leading to more frequent recent experiences of racial microaggressions.

Discussion

This study focuses on AI individuals with a diagnosis of T2D, a condition linked to stress and trauma exposure (Jiang et al., 2008; Surwit et al., 1992; Walders-Abramson et al., 2014). Research and initiatives to address and understand HT within AI communities has increased significantly over the past few decades. There are numerous proposed mechanisms for how HT can affect current/future generations, including as an etiological agent to distress (Walters et al., 2011), a trauma response (Braveheart, 1999), and a historical stressor interacting with other contemporary stressors (Whitbeck et al., 2004). It is important to assess and consider multiple dimensions of HT given numerous definitions, dimensions, and understandings of this concept. This present study moved beyond prior literature to examine familial and personal experiences with relocation, boarding school, and foster care exposure as indicators of HT to determine their relationship with internalizing symptoms and experiences of discrimination and cultural losses among a sample of AI adults with T2D. We tested if historical cultural losses (a more contemporary assessment of HT) and microaggressions served as mediating pathways through which HT relates to internalizing outcomes. Results highlight the importance of measuring both distal (i.e., personal and familial HT-related experiences like boarding schools and relocation) and contemporary (i.e., thoughts of cultural loss; microaggressions) indicators of marginalization as predictors of psychological distress for AIs.

Findings from this study did not support hypothesis 1 or 2; results did not show any direct association between ancestral HT, foster care, or historical losses and participant internalizing symptoms. This finding was contrary to other studies that found a direct correlation to increasing internalizing symptoms with regards to ancestral participation in relocation programs (Walls & Whitbeck, 2012b). However, this study did support hypothesis 3 where experiences of microaggressions were positively associated with internalizing symptoms. Additionally, we did find support for hypothesis 6, that there is an indirect relationship between indicators of HT and greater reports of internalizing symptoms through increased experiences of microaggressions and cultural loss. Thus, and in alignment with the concept of historical oppression, contemporary discrimination is a possible mediating link between HT and contemporary internalizing symptoms. This also builds upon prior research findings of how historical losses are associated with increased internalizing symptoms and perceived discrimination in both adults and adolescents (Whitbeck et al., 2009; Whitbeck et al., 2004). Additionally, this study includes foster care and relocation associated with internalizing symptoms and adds to previous literature where negative communication regarding parents’ boarding school experiences was related to greater perceived discrimination and depressive symptoms (Matheson et al., 2019). As such, recent experiences of racial microaggressions are a contributing factor through which historical trauma and losses lead to internalizing symptoms.

There were mixed results for hypothesis 4; consistent with prior studies (Bombay et al., 2011; Walls and Whitbeck, 2012a), ancestral experience of boarding school and personal experience with foster care were each directly associated with increased thoughts of cultural loss. We did not find a direct association between relocation and cultural loss. One speculation for incongruent findings could be that some factors may be protective against thoughts of cultural loss such as strong cultural identity and social support from other relocatees. This may serve to offset poor mental health outcomes for those who have been relocated. Blackhawk (1995) writes about how despite BIA attempting to colonize AI by removal and relocation, they “… creatively negotiated their different cultural systems to meet their new environments” (p. 17).

In support of hypothesis 5, we found a direct relationship between HT and cultural losses with microaggressions. Similarly, past studies have shown those who attended residential schools perceive higher levels of discrimination and increased depressive symptoms (Bombay, 2014a). These findings bolster the recent literature on historical oppression and demonstrate how microaggressions impact current mental health outcomes (BraveHeart, 2003) and are associated with worsening depression (Walls et al., 2015) and other psychological symptoms (Matheson et al., 2019).

As previously stated, we found that for individuals in foster care there was a direct association with increased thoughts of cultural loss. Understanding the experiences of AIs in foster care remains an area that demands extensive research and scholarly attention. In the U.S., each year over 20,000 young adults age out of the foster care system (US Department of Health & Human Services, 1999). Regardless of race, many of them face homelessness, lack of unemployment, and incarceration (Reilly, 2003). These effects are amplified by colonization policies and cultural loss for AIs. In the early 1970s, as many as one in four AI children were removed from their homes (Jones et al., 2008). Today, AIs are still overrepresented in foster care (US Department of Health & Human Services, 2019). Nearly one-quarter of the participants in the current study experienced childhood placement in foster care, and these participants thought about historical losses significantly more often than those without a foster care history. Supporting H6, those with foster care histories and those whose ancestors experienced boarding schools reported increased symptoms of depression, anxiety, and loneliness indirectly through microaggression exposure and increased thoughts of historical loss. These findings suggest that boarding school and foster care histories are pathways to feeling cultural disconnection and loss that impacts contemporary mental health and discrimination for AI adults.

Our conceptualization of colonization policies is congruent with current historical trauma scholarship and extends previous literature for AIs with T2D. The AI population has the highest rate of T2D in the U.S. (Blackwell et al., 2014). Prior studies show that experience of microaggressions increases the risk of developing T2D in AIs (Jiang et al., 2008) and is associated with worse health in those already living with the disease, along with decreased healthy eating habits and exercise (Sittner et al., 2018). Congruent with the U.S. population overall (Karg et al., 2014), AI women in this study were found to have higher levels of internalizing symptoms compared to their male counterparts. A previous study by Sittner (2018) found that lower medication adherence in females was attributed to their diabetes distress and depression. Implications from this study amplify how historically traumatic events and present-day experiences with marginalization may shape the health of AI people by influencing heightened internalizing symptoms.

Limitations and future directions

These findings should be interpreted with limitations in mind. First, this research focuses on a clinic-based sample of adults living with T2D. While T2D rates are high in AI communities, relying on a clinic sample of participants who seek formal services may introduce sample bias. Second, findings cannot be generalized to AI people who did not seek treatment for diabetes, those who have undiagnosed T2D, or those who receive care outside of reservation facilities. It is also important to recognize that internalizing symptoms play an important part in T2D among AIs given the connection to worse disease outcomes. Ancestral history is also self-reported which may not be accurately passed down to future generations for a variety of reasons. There are 574 federally recognized tribes in the U.S. and many more which are not recognized. There is significant diversity between communities, which also affects the generalizability of these findings. Third, discrimination and internalizing symptoms were measured concurrently, and time ordering cannot be established. Decades of research, however, show consistent and strong associations between discrimination as an antecedent to various mental health outcomes (Matheson et al., 2019; Williams-Morris, 2000).

Our analyses also signal potential for future research. As one example, it could be possible that more distal (HT) and contemporary measures of stress/trauma interact to influence internalizing symptoms. Future research could explore such moderating/interacting pathways. The current study focused on the relationship between HT and microaggressions in relation to mental health in those with T2D; looking more broadly at how discrimination impacts physical health and access to health care could add to existing literature and identify potential barriers to receiving care. For instance, future work might include AIs with other chronic medical conditions and/or assess microaggressions related specifically to healthcare experiences, which might add predictive power to the current findings.

Of particular importance and missing from our current approach is attention to sources of Indigenous strength and resilience that foster myriad positive outcomes even in the face of disproportionate exposure to historical trauma and oppression (Fast & Collin-Vezina, 2010). An important step for HT-related research is to understand the factors (e.g., culture, community, connectedness, etc.; Ullrich, 2019) that allow many AIs to overcome or resist health deficits, a point especially critical to strengths-based public health programming and clinical services.

Conclusion

This study bolsters prior historical trauma research by demonstrating how foster care, boarding school, and relocation are linked to contemporary HT-related stressors (i.e., historical loss) and experiences of microaggressions. Findings for this study of AIs with T2D reveal how distal indicators of HT influence more contemporary accounts of cultural loss, each of which are related to experiences with microaggressions. These mediated pathways can likely further influence heightened reports of internalizing symptoms (e.g., indirect effects). Complex relationships show how history is inextricably intertwined with the present day to influence unequal outcomes for AI peoples. Although this study did not focus specifically on clinical experiences, results have relevance to clinicians and social service providers to understand the potential consequences of historical and contemporary marginalization, including microaggressive interactions and the contexts in which they occur. This research highlights the importance of recognizing the contentious history of colonialism that should be considered during clinical and health and human service interactions (Evans-Campbell, 2008) and underscores the need for cultural awareness and humility in healthcare and social service settings.

Historical cultural loss
Factor 1
Taking of our land
Separation of family ties because of boarding or residential schools
Removal of families from the reservation due to government relocation
Loss of trust in whites from broken treaties
Factor 2
Fewer people using traditional language
Attacks on traditional spiritual ways
Factor 3
Destruction of our culture
Loss of respect for elders by our children and grandchildren
Loss of respect by our children for traditional ways
Damages to our sense of community
Destruction or damage of traditional foods
Taking of family members by non-Native foster care or adoption placements
Destruction of natural resources and beauty due to pollution, mining, and other industries
Microaggressions
Being called something racist, such as Chief, Wahoo, Squaw, Indian Giver, Savage, or Pocahontas?
Feeling like Native people are “invisible” to the rest of society?
Hearing from non-Natives how surprisingly well-read or smart you are?
Feeling stereotyped by non-Native persons?
Seeing portrayals of Native people in TV, movies, or as sports mascots?
Someone suspecting you of doing something wrong because you are Native, for example being followed in stores or hassled by police?
People acting as if they are afraid of you because you are Native?
People accusing you of being oversensitive when you try to discuss race issues or racism.
Feeling like you are treated differently because of your race or ethnicity?

	Mean	S.D.	Alpha	Proportion missing
Female	0.56			0.00
Age	46.32	12.51		0.00
Per capita family income (per US$1,000)	9.77	8.88		0.01
Resides on reservation land	0.79			0.00
Years with type 2 diabetes	1.58	1.48		0.02
Foster care	0.23			0.02
Parent/grandparent boarding school	0.62			0.10
Parent/grandparent relocation	0.28			0.02
Historical loss factor 1	1.38	1.18	0.87	0.01
Historical loss factor 2	2.10	1.25	0.92	0.01
Historical loss factor 3	1.92	1.30	0.82	0.01
Microaggressions parcel 1	1.55	1.50	0.83	0.15
Microaggressions parcel 2	2.46	1.92	0.83	0.15
Microaggressions parcel 3	1.91	1.78	0.83	0.15
PHQ-9 depressive symptoms	4.75	4.86	0.85	0.15
GAD-7 anxiety symptoms	4.27	4.85	0.92	0.15
Loneliness	3.99	4.07	0.87	0.15

	Historical loss (W1)	Microaggressions (W2)	Internalizing symptoms (W2)
Foster care	0.30* [0.03, 0.57]	0.13	−0.12 [−0.52, 0.29]	−0.05	0.68 [−1.15, 2.52]	0.07
Parent/grandparent boarding school	0.74** [0.43, 1.06]	0.38	0.28 [−0.13, 0.69]	0.14	0.30 [−1.16, 1.75]	0.03
Parent/grandparent relocation	0.26 [−0.06, 0.58]	0.12	0.37⁺ [−0.03, 0.77]	0.17	−0.73 [−2.29, 0.85]	−0.07
Historical loss (W1)			0.26* [0.02, 0.51]	0.25	−0.11 [−0.94, 0.71]	−0.03
Microaggressions (W2)					1.52** [0.59, 2.44]	0.34
Female	−0.09 [−0.36, 0.17]	−0.05	−0.01 [−0.32, 0.31]	−0.00	2.08** [0.62, 3.53]	0.24
Age	0.07 [−0.01, 0.02]	0.09	−0.00 [−0.02, 0.02]	−0.02	−0.03 [−0.10, 0.02]	−0.11
Per capita family income	−0.01⁺ [−0.03, 0.00]	−0.02	0.00 [−0.02, 0.02]	0.03	−0.08* [−0.15. −0.01]	−0.16
On reservation	−0.06 [−0.44, 0.32]	−0.03	0.14 [−0.23, 0.50]	0.06	−0.29 [−1.83, 1.24]	−0.03
Years with type 2 diabetes	−0.06 [−0.15, 0.03]	−0.01	0.00 [−0.11, 0.11]	0.01	0.17 [−0.49 0.84]	0.06

Footnotes

Acknowledgements

The Gathering for Health Team includes contributions from numerous tribally-based team members, including: Sidnee Kellar, Rose Barber, Robert Miller, Tweed Shuman, Lorraine Smith, Sandy Zeznanski, Patty Subera, Tracy Martin, Julie Yaekel-Black Elk, Geraldine Whiteman, Trisha Prentice, Alexis Mason, Charity Prentice-Pemberton, Kathy Dudley, Romona Nelson, Eileen Miller, Geraldine Brun, Murphy Thomas, Mary Sikora-Petersen, Tina Handeland, GayeAnn Allen, Frances Whitfield, Phillip Chapman, Sr., Sonya Psuik, Hope Williams, Betty Jo Graveen, Daniel Chapman, Jr., Doris Isham, Stan Day, Jane Villebrun, Beverly Steel, Muriel Deegan, Peggy Connor, Michael Connor, Ray E. Villebrun, Sr., Pam Hughes, Cindy McDougall, Melanie McMichael, Robert Thompson, and Sandra Kier.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Research reported in this article was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (DK091250, M. Walls, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Stefanie L. Gillson

Stefanie L. Gillson, MD, is Dakota-Sioux and a Child and Adolescent Psychiatry Fellow at Yale Child Study Center. She finished her General Psychiatry Residency and Public Psychiatry Fellowship at Yale University. She is currently a scholar at the Johns Hopkins Center for American Indian Health within the Bloomberg School of Public Health and an American Psychiatric Association SAMHSA Minority Fellow where her research and service portfolio focus on developing community-based initiatives to address mental health disparities among Indigenous communities through a historical and contemporary lens.

Dane Hautala, PhD, is an Assistant Scientist in the Department of International Health and Center for American Indian Health, Great Lakes Hub at the Johns Hopkins Bloomberg School of Public Health. His research focuses on etiology and consequences of substance use and recovery across the early life course among Indigenous people.

Kelley J. Sittner, PhD, is an associate professor in the Department of Sociology at Oklahoma State University, Stillwater, Oklahoma, the United States. She works collaboratively with tribal communities to study health and wellbeing across the life-course of Indigenous youth and adults.

Melissa Walls, PhD, is an Anishinaabe social scientist working in collaboration with Indigenous communities in the United States and Canada on health equity research and culturally relevant public health programming. She is an Associate Professor of American Health at the Johns Hopkins Bloomberg School of Public Health and Director of the Great Lakes Hub of the JHU Center for American Indian Health. Dr. Walls is the PI with a longstanding research team that includes Anishinaabe community members and academic researchers working together to understand and address the social, historical, and contemporary determinants of unequal health outcomes. The team's work is largely funded by the National Institutes of Health (NIDA and NIDDK).

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	Historical loss (W1)		Microaggressions (W2)		Internalizing symptoms (W2)
	b [95% CI]	β	b [95% CI]	β	b [95% CI]	β
Foster care	0.30* [0.03, 0.57]	0.13	−0.12 [−0.52, 0.29]	−0.05	0.68 [−1.15, 2.52]	0.07
Parent/grandparent boarding school	0.74** [0.43, 1.06]	0.38	0.28 [−0.13, 0.69]	0.14	0.30 [−1.16, 1.75]	0.03
Parent/grandparent relocation	0.26 [−0.06, 0.58]	0.12	0.37⁺ [−0.03, 0.77]	0.17	−0.73 [−2.29, 0.85]	−0.07
Historical loss (W1)			0.26* [0.02, 0.51]	0.25	−0.11 [−0.94, 0.71]	−0.03
Microaggressions (W2)					1.52** [0.59, 2.44]	0.34
Female	−0.09 [−0.36, 0.17]	−0.05	−0.01 [−0.32, 0.31]	−0.00	2.08** [0.62, 3.53]	0.24
Age	0.07 [−0.01, 0.02]	0.09	−0.00 [−0.02, 0.02]	−0.02	−0.03 [−0.10, 0.02]	−0.11
Per capita family income	−0.01⁺ [−0.03, 0.00]	−0.02	0.00 [−0.02, 0.02]	0.03	−0.08* [−0.15. −0.01]	−0.16
On reservation	−0.06 [−0.44, 0.32]	−0.03	0.14 [−0.23, 0.50]	0.06	−0.29 [−1.83, 1.24]	−0.03
Years with type 2 diabetes	−0.06 [−0.15, 0.03]	−0.01	0.00 [−0.11, 0.11]	0.01	0.17 [−0.49 0.84]	0.06