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Historical trauma and current social factors contribute to depression, PTSD, anxiety disorders
The history of abuse and genocide has its precursors in antiquity. A brief sketch of this history will provide some insights into the impact of intergenerational trauma and a rationale for the crisis of missing and murdered Indigenous women and girls in the United States and Canada, or Turtle Island, as the Indigenous People call it.
Such a review also will provide a partial explanation of why the suicide rate among non-Hispanic Native American or Alaska Native women increased by 139%1 during 1999-2017 – a time when more Indigenous women were gaining access to law and medical school, as well as positions of authority in their tribes.
Church-, state-sanctioned transgressions
The psychological impact of our past history haunts us today. Papal bulletins – decrees from the pope – gave permission to Christian explorers to take land, wealth, and slaves from any nonbeliever. This permission was labeled the Doctrine of Discovery. It was incorporated into U.S. law in 1823, and by the Supreme Court case, Johnson v. M’intosh. It also provided rationale for the Indian Removal Act, which was passed on May 28, 1830, and signed into law by U.S. President Andrew Jackson. As a result of that law, Indigenous People were forced onto reservations, often removed from their traditional and sacred homelands. Many died during forced relocation.2
From the time of “discovery” by settlers until well into the 19th century, the U.S. governmental intent was genocide. It was manifest by the outright murder of Indigenous People, displacement from land, and the disruption of families when children were taken, put into boarding schools, and were forbidden to speak their language. Indigenous medicine people were killed or jailed for practicing their traditional ceremonies. Indigenous nations had their laws, languages, and agricultural practices denied them. Even today, they must practice U.S. law, adapt colonizing forms of land ownership, and engage in the economic practices of the dominant culture. The economic system currently in place rewards rape of the land and creates a trickle-up economy that keeps rewarding the rich at the expense of the poor. The economic system even gives corporations legal status as individuals, and, in some cases, is allowed to supersede the rights of Indigenous nations.
Today, the federal government still can appropriate land for minerals, pipelines,3 and even put indigenous land and water sovereignty at risk of contamination and pollution by mines established upstream.4 Most of those practices are repugnant to Indigenous nations. The Doctrine of Discovery established prior to 1492 is still alive and well on Turtle Island.
It is this background that denies the rights of Mother Earth, and this backdrop that, in turn, generalizes the denial of the rights of Indigenous women. There are women today, who, against their will and knowledge, have been sterilized.5 There are cases in which women have been raped and beaten, and their perpetrators were never been brought to justice.6 There are jurisdictional issues in the federal law that keep non-native perpetrators from being punished for their actions on tribal sovereign land.
This history and those current practices affect Indigenous families. Historical trauma produces epigenetic changes7 that create more anxiety and depression. Families in which one or both parents were taken away have a harder time providing a loving, safe, addiction-free environment for their children. Children often have high scores on measurements of adverse childhood experiences and suffer PTSD. As psychiatrists, we have treated PTSD from residential and boarding school survivors, families with family members who were victims of being missing or murdered, and survivors of sexual abuse – both in the United States and Canada. According to the final Canadian report of the inquiry into missing and murdered Indigenous women and girls, the murder rate for Indigenous women was 12 times that of non-Indigenous women.8
We assert that this combination of historical trauma and current social factors contributes to depression, PTSD, and anxiety disorders that currently feed the rise in attempted and completed suicide. Less-than-optimal educational opportunities and unemployment, often above 10% on reservations,9 along with food insecurity, accentuate the settings in which women and girls live.
Women achieving despite challenges
Yet, Indigenous women are making great strides within their cultures and communities. For example, Indigenous women are leading language revitalization, and within their culture, are healers and carriers of knowledge. Many Indigenous women are doctors, lawyers, dentists, teachers, poets, authors, and artists.10 Voters in last year’s midterms elected two Native American women to the U.S. Congress. Often, however, those achievements within the Western culture come at a cost, and some might have difficulty balancing those roles with their traditional cultures.
Current societal pressures feed the rise of suicide. Santa Fe, N.M., is known for its affluence and reputation as a tricultural city of Anglos, Hispanics, and Native Americans, and yet, a recent health impact assessment survey of urban Indigenous families stated that food insecurity was the leading concern for those families. Unemployment on the Navajo Nation is above 50%.11 The Indian Health Service (IHS) in the United States, which provides the majority of mental services to the Indigenous population, has identified mental health issues as the No. 1 health problem. However, only 7% of the IHS budget is allocated for mental health and substance abuse services. This represents an underfudging of services to American Indian and Alaska Native communities. In fact, there were only two psychiatrists per 100,000 people served by the IHS, which is one-seventh the number of psychiatrists available to the general population in the United States.12
Best practices for psychiatrists working with Indigenous women demands that we know the history, know how that history is still being manifest in subtle ways, and understand how such antiquated papal bulletins as the Doctrine of Discovery still operate to justify the taking and misuse of indigenous land. We must realize that the dominant economic systems, laws, and policing strategies are imposed on cultures that are sophisticated in their own right. This will then allow compassionate care with a level of understanding.
13
We can advocate at all levels, considering that the role of the federal government, the state, corporations, tribes, families, and provision of quality care to individuals can continue the positive collective advancement of women, and reduce the morbidity and mortality associated with suicide attempts.
We need to be sensitive to our patients and their risks of suicide. Treat suicidal ideation as the serious threat that it is. Address the depression, anxiety, PTSD, historical trauma, substance abuse, emotional dysregulation, and loss of relationship in persons with attachment disorders as serious and valid life events than can lead to serious consequences – including completed suicide.
Indigenous women are resilient, and the approach should be to also balance knowledge of those potential barriers with validating the feminine, and supporting the traditional roles of women and men that value women and children, and revere the matriarchs. Encouraging and supporting Indigenous resurgence of cultural practices and values is significant for positive outcomes for healing and wellness. Doing so can carry a greater meaning within Indigenous and First Nations society.
References
1. Curtin SC and H Hedegaard. Suicide rates for females and males by race and ethnicity: United States, 1999 and 2017. NCHS Health E-Stat. 2019.
2. Anderson GC. Ethnic cleansing and the Indian: The crime that should haunt America. Norman, Okla.: University of Oklahoma Press, 2014.
3. Rausch N. “Standing Rock, Morton County work to mend relationships post-DAPL protests.” Billingsgazette.com. Aug 10, 2019.
4. Roy A. “5 ways the government keeps Native Americans in poverty.” Forbes.com. Mar 13, 2014.
5. Blakemore E. “The little-known history of forced sterilization of Native American women.” JSTOR.org. Aug 25, 2016.
6. Bleir G and A Zoledziowski. “Murdered and missing Native American women challenge police and courts.” Publicintegrity.org. Aug 27, 2018.
7. Brockie TN et al. A framework to examine the role of epigenetics in health disparities among Native Americans. Nurs Res Prac. 2013;2013:410395.
8. “Reclaiming power and place: The final report of the national inquiry into missing and murdered Indigenous women and girls.” Vancouver: Privy Office. Jun 3, 2019.
9. Hagan S. “Where U.S. unemployment is still sky-high: Indian reservations.” Bloomberg.com. Apr 5, 2018.
10. Morin B. “Meet 10 Indigenous women who are making the world a better place.” Indian Country Today. Jul 1, 2019.
11. Fact sheet. Discovernavajo.com.
12. Sarche M and P Spicer. Poverty and health disparities for American Indian and Alaska Native children: Current knowledge and future prospects. Ann NY Acad Sci. 2008 Jul 25;1136:126-36.
13. Lewis-Fernández R et al. Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry. 2014 Summer;77(2):130-54.
Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local Indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association.
Dr. Neidhardt is a board-certified psychiatrist who lives in Santa Fe and has an integrative, holistic psychiatric practice that also specializes in trauma-focused therapy. He has provided care for Indigenous People in the Southwest United States and in Canada, and has worked with Navajo medicine people to develop training for mental health professionals with his wife, Dr. Mary Hasbah Roessel. Dr. Reinhardt is a life fellow of the APA.
Historical trauma and current social factors contribute to depression, PTSD, anxiety disorders
Historical trauma and current social factors contribute to depression, PTSD, anxiety disorders
The history of abuse and genocide has its precursors in antiquity. A brief sketch of this history will provide some insights into the impact of intergenerational trauma and a rationale for the crisis of missing and murdered Indigenous women and girls in the United States and Canada, or Turtle Island, as the Indigenous People call it.
Such a review also will provide a partial explanation of why the suicide rate among non-Hispanic Native American or Alaska Native women increased by 139%1 during 1999-2017 – a time when more Indigenous women were gaining access to law and medical school, as well as positions of authority in their tribes.
Church-, state-sanctioned transgressions
The psychological impact of our past history haunts us today. Papal bulletins – decrees from the pope – gave permission to Christian explorers to take land, wealth, and slaves from any nonbeliever. This permission was labeled the Doctrine of Discovery. It was incorporated into U.S. law in 1823, and by the Supreme Court case, Johnson v. M’intosh. It also provided rationale for the Indian Removal Act, which was passed on May 28, 1830, and signed into law by U.S. President Andrew Jackson. As a result of that law, Indigenous People were forced onto reservations, often removed from their traditional and sacred homelands. Many died during forced relocation.2
From the time of “discovery” by settlers until well into the 19th century, the U.S. governmental intent was genocide. It was manifest by the outright murder of Indigenous People, displacement from land, and the disruption of families when children were taken, put into boarding schools, and were forbidden to speak their language. Indigenous medicine people were killed or jailed for practicing their traditional ceremonies. Indigenous nations had their laws, languages, and agricultural practices denied them. Even today, they must practice U.S. law, adapt colonizing forms of land ownership, and engage in the economic practices of the dominant culture. The economic system currently in place rewards rape of the land and creates a trickle-up economy that keeps rewarding the rich at the expense of the poor. The economic system even gives corporations legal status as individuals, and, in some cases, is allowed to supersede the rights of Indigenous nations.
Today, the federal government still can appropriate land for minerals, pipelines,3 and even put indigenous land and water sovereignty at risk of contamination and pollution by mines established upstream.4 Most of those practices are repugnant to Indigenous nations. The Doctrine of Discovery established prior to 1492 is still alive and well on Turtle Island.
It is this background that denies the rights of Mother Earth, and this backdrop that, in turn, generalizes the denial of the rights of Indigenous women. There are women today, who, against their will and knowledge, have been sterilized.5 There are cases in which women have been raped and beaten, and their perpetrators were never been brought to justice.6 There are jurisdictional issues in the federal law that keep non-native perpetrators from being punished for their actions on tribal sovereign land.
This history and those current practices affect Indigenous families. Historical trauma produces epigenetic changes7 that create more anxiety and depression. Families in which one or both parents were taken away have a harder time providing a loving, safe, addiction-free environment for their children. Children often have high scores on measurements of adverse childhood experiences and suffer PTSD. As psychiatrists, we have treated PTSD from residential and boarding school survivors, families with family members who were victims of being missing or murdered, and survivors of sexual abuse – both in the United States and Canada. According to the final Canadian report of the inquiry into missing and murdered Indigenous women and girls, the murder rate for Indigenous women was 12 times that of non-Indigenous women.8
We assert that this combination of historical trauma and current social factors contributes to depression, PTSD, and anxiety disorders that currently feed the rise in attempted and completed suicide. Less-than-optimal educational opportunities and unemployment, often above 10% on reservations,9 along with food insecurity, accentuate the settings in which women and girls live.
Women achieving despite challenges
Yet, Indigenous women are making great strides within their cultures and communities. For example, Indigenous women are leading language revitalization, and within their culture, are healers and carriers of knowledge. Many Indigenous women are doctors, lawyers, dentists, teachers, poets, authors, and artists.10 Voters in last year’s midterms elected two Native American women to the U.S. Congress. Often, however, those achievements within the Western culture come at a cost, and some might have difficulty balancing those roles with their traditional cultures.
Current societal pressures feed the rise of suicide. Santa Fe, N.M., is known for its affluence and reputation as a tricultural city of Anglos, Hispanics, and Native Americans, and yet, a recent health impact assessment survey of urban Indigenous families stated that food insecurity was the leading concern for those families. Unemployment on the Navajo Nation is above 50%.11 The Indian Health Service (IHS) in the United States, which provides the majority of mental services to the Indigenous population, has identified mental health issues as the No. 1 health problem. However, only 7% of the IHS budget is allocated for mental health and substance abuse services. This represents an underfudging of services to American Indian and Alaska Native communities. In fact, there were only two psychiatrists per 100,000 people served by the IHS, which is one-seventh the number of psychiatrists available to the general population in the United States.12
Best practices for psychiatrists working with Indigenous women demands that we know the history, know how that history is still being manifest in subtle ways, and understand how such antiquated papal bulletins as the Doctrine of Discovery still operate to justify the taking and misuse of indigenous land. We must realize that the dominant economic systems, laws, and policing strategies are imposed on cultures that are sophisticated in their own right. This will then allow compassionate care with a level of understanding.
13
We can advocate at all levels, considering that the role of the federal government, the state, corporations, tribes, families, and provision of quality care to individuals can continue the positive collective advancement of women, and reduce the morbidity and mortality associated with suicide attempts.
We need to be sensitive to our patients and their risks of suicide. Treat suicidal ideation as the serious threat that it is. Address the depression, anxiety, PTSD, historical trauma, substance abuse, emotional dysregulation, and loss of relationship in persons with attachment disorders as serious and valid life events than can lead to serious consequences – including completed suicide.
Indigenous women are resilient, and the approach should be to also balance knowledge of those potential barriers with validating the feminine, and supporting the traditional roles of women and men that value women and children, and revere the matriarchs. Encouraging and supporting Indigenous resurgence of cultural practices and values is significant for positive outcomes for healing and wellness. Doing so can carry a greater meaning within Indigenous and First Nations society.
References
1. Curtin SC and H Hedegaard. Suicide rates for females and males by race and ethnicity: United States, 1999 and 2017. NCHS Health E-Stat. 2019.
2. Anderson GC. Ethnic cleansing and the Indian: The crime that should haunt America. Norman, Okla.: University of Oklahoma Press, 2014.
3. Rausch N. “Standing Rock, Morton County work to mend relationships post-DAPL protests.” Billingsgazette.com. Aug 10, 2019.
4. Roy A. “5 ways the government keeps Native Americans in poverty.” Forbes.com. Mar 13, 2014.
5. Blakemore E. “The little-known history of forced sterilization of Native American women.” JSTOR.org. Aug 25, 2016.
6. Bleir G and A Zoledziowski. “Murdered and missing Native American women challenge police and courts.” Publicintegrity.org. Aug 27, 2018.
7. Brockie TN et al. A framework to examine the role of epigenetics in health disparities among Native Americans. Nurs Res Prac. 2013;2013:410395.
8. “Reclaiming power and place: The final report of the national inquiry into missing and murdered Indigenous women and girls.” Vancouver: Privy Office. Jun 3, 2019.
9. Hagan S. “Where U.S. unemployment is still sky-high: Indian reservations.” Bloomberg.com. Apr 5, 2018.
10. Morin B. “Meet 10 Indigenous women who are making the world a better place.” Indian Country Today. Jul 1, 2019.
11. Fact sheet. Discovernavajo.com.
12. Sarche M and P Spicer. Poverty and health disparities for American Indian and Alaska Native children: Current knowledge and future prospects. Ann NY Acad Sci. 2008 Jul 25;1136:126-36.
13. Lewis-Fernández R et al. Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry. 2014 Summer;77(2):130-54.
Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local Indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association.
Dr. Neidhardt is a board-certified psychiatrist who lives in Santa Fe and has an integrative, holistic psychiatric practice that also specializes in trauma-focused therapy. He has provided care for Indigenous People in the Southwest United States and in Canada, and has worked with Navajo medicine people to develop training for mental health professionals with his wife, Dr. Mary Hasbah Roessel. Dr. Reinhardt is a life fellow of the APA.
The history of abuse and genocide has its precursors in antiquity. A brief sketch of this history will provide some insights into the impact of intergenerational trauma and a rationale for the crisis of missing and murdered Indigenous women and girls in the United States and Canada, or Turtle Island, as the Indigenous People call it.
Such a review also will provide a partial explanation of why the suicide rate among non-Hispanic Native American or Alaska Native women increased by 139%1 during 1999-2017 – a time when more Indigenous women were gaining access to law and medical school, as well as positions of authority in their tribes.
Church-, state-sanctioned transgressions
The psychological impact of our past history haunts us today. Papal bulletins – decrees from the pope – gave permission to Christian explorers to take land, wealth, and slaves from any nonbeliever. This permission was labeled the Doctrine of Discovery. It was incorporated into U.S. law in 1823, and by the Supreme Court case, Johnson v. M’intosh. It also provided rationale for the Indian Removal Act, which was passed on May 28, 1830, and signed into law by U.S. President Andrew Jackson. As a result of that law, Indigenous People were forced onto reservations, often removed from their traditional and sacred homelands. Many died during forced relocation.2
From the time of “discovery” by settlers until well into the 19th century, the U.S. governmental intent was genocide. It was manifest by the outright murder of Indigenous People, displacement from land, and the disruption of families when children were taken, put into boarding schools, and were forbidden to speak their language. Indigenous medicine people were killed or jailed for practicing their traditional ceremonies. Indigenous nations had their laws, languages, and agricultural practices denied them. Even today, they must practice U.S. law, adapt colonizing forms of land ownership, and engage in the economic practices of the dominant culture. The economic system currently in place rewards rape of the land and creates a trickle-up economy that keeps rewarding the rich at the expense of the poor. The economic system even gives corporations legal status as individuals, and, in some cases, is allowed to supersede the rights of Indigenous nations.
Today, the federal government still can appropriate land for minerals, pipelines,3 and even put indigenous land and water sovereignty at risk of contamination and pollution by mines established upstream.4 Most of those practices are repugnant to Indigenous nations. The Doctrine of Discovery established prior to 1492 is still alive and well on Turtle Island.
It is this background that denies the rights of Mother Earth, and this backdrop that, in turn, generalizes the denial of the rights of Indigenous women. There are women today, who, against their will and knowledge, have been sterilized.5 There are cases in which women have been raped and beaten, and their perpetrators were never been brought to justice.6 There are jurisdictional issues in the federal law that keep non-native perpetrators from being punished for their actions on tribal sovereign land.
This history and those current practices affect Indigenous families. Historical trauma produces epigenetic changes7 that create more anxiety and depression. Families in which one or both parents were taken away have a harder time providing a loving, safe, addiction-free environment for their children. Children often have high scores on measurements of adverse childhood experiences and suffer PTSD. As psychiatrists, we have treated PTSD from residential and boarding school survivors, families with family members who were victims of being missing or murdered, and survivors of sexual abuse – both in the United States and Canada. According to the final Canadian report of the inquiry into missing and murdered Indigenous women and girls, the murder rate for Indigenous women was 12 times that of non-Indigenous women.8
We assert that this combination of historical trauma and current social factors contributes to depression, PTSD, and anxiety disorders that currently feed the rise in attempted and completed suicide. Less-than-optimal educational opportunities and unemployment, often above 10% on reservations,9 along with food insecurity, accentuate the settings in which women and girls live.
Women achieving despite challenges
Yet, Indigenous women are making great strides within their cultures and communities. For example, Indigenous women are leading language revitalization, and within their culture, are healers and carriers of knowledge. Many Indigenous women are doctors, lawyers, dentists, teachers, poets, authors, and artists.10 Voters in last year’s midterms elected two Native American women to the U.S. Congress. Often, however, those achievements within the Western culture come at a cost, and some might have difficulty balancing those roles with their traditional cultures.
Current societal pressures feed the rise of suicide. Santa Fe, N.M., is known for its affluence and reputation as a tricultural city of Anglos, Hispanics, and Native Americans, and yet, a recent health impact assessment survey of urban Indigenous families stated that food insecurity was the leading concern for those families. Unemployment on the Navajo Nation is above 50%.11 The Indian Health Service (IHS) in the United States, which provides the majority of mental services to the Indigenous population, has identified mental health issues as the No. 1 health problem. However, only 7% of the IHS budget is allocated for mental health and substance abuse services. This represents an underfudging of services to American Indian and Alaska Native communities. In fact, there were only two psychiatrists per 100,000 people served by the IHS, which is one-seventh the number of psychiatrists available to the general population in the United States.12
Best practices for psychiatrists working with Indigenous women demands that we know the history, know how that history is still being manifest in subtle ways, and understand how such antiquated papal bulletins as the Doctrine of Discovery still operate to justify the taking and misuse of indigenous land. We must realize that the dominant economic systems, laws, and policing strategies are imposed on cultures that are sophisticated in their own right. This will then allow compassionate care with a level of understanding.
13
We can advocate at all levels, considering that the role of the federal government, the state, corporations, tribes, families, and provision of quality care to individuals can continue the positive collective advancement of women, and reduce the morbidity and mortality associated with suicide attempts.
We need to be sensitive to our patients and their risks of suicide. Treat suicidal ideation as the serious threat that it is. Address the depression, anxiety, PTSD, historical trauma, substance abuse, emotional dysregulation, and loss of relationship in persons with attachment disorders as serious and valid life events than can lead to serious consequences – including completed suicide.
Indigenous women are resilient, and the approach should be to also balance knowledge of those potential barriers with validating the feminine, and supporting the traditional roles of women and men that value women and children, and revere the matriarchs. Encouraging and supporting Indigenous resurgence of cultural practices and values is significant for positive outcomes for healing and wellness. Doing so can carry a greater meaning within Indigenous and First Nations society.
References
1. Curtin SC and H Hedegaard. Suicide rates for females and males by race and ethnicity: United States, 1999 and 2017. NCHS Health E-Stat. 2019.
2. Anderson GC. Ethnic cleansing and the Indian: The crime that should haunt America. Norman, Okla.: University of Oklahoma Press, 2014.
3. Rausch N. “Standing Rock, Morton County work to mend relationships post-DAPL protests.” Billingsgazette.com. Aug 10, 2019.
4. Roy A. “5 ways the government keeps Native Americans in poverty.” Forbes.com. Mar 13, 2014.
5. Blakemore E. “The little-known history of forced sterilization of Native American women.” JSTOR.org. Aug 25, 2016.
6. Bleir G and A Zoledziowski. “Murdered and missing Native American women challenge police and courts.” Publicintegrity.org. Aug 27, 2018.
7. Brockie TN et al. A framework to examine the role of epigenetics in health disparities among Native Americans. Nurs Res Prac. 2013;2013:410395.
8. “Reclaiming power and place: The final report of the national inquiry into missing and murdered Indigenous women and girls.” Vancouver: Privy Office. Jun 3, 2019.
9. Hagan S. “Where U.S. unemployment is still sky-high: Indian reservations.” Bloomberg.com. Apr 5, 2018.
10. Morin B. “Meet 10 Indigenous women who are making the world a better place.” Indian Country Today. Jul 1, 2019.
11. Fact sheet. Discovernavajo.com.
12. Sarche M and P Spicer. Poverty and health disparities for American Indian and Alaska Native children: Current knowledge and future prospects. Ann NY Acad Sci. 2008 Jul 25;1136:126-36.
13. Lewis-Fernández R et al. Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry. 2014 Summer;77(2):130-54.
Dr. Roessel is a Navajo board-certified psychiatrist practicing in Santa Fe, N.M., working with the local Indigenous population. She has special expertise in cultural psychiatry; her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles. Dr. Roessel is a distinguished fellow of the American Psychiatric Association.
Dr. Neidhardt is a board-certified psychiatrist who lives in Santa Fe and has an integrative, holistic psychiatric practice that also specializes in trauma-focused therapy. He has provided care for Indigenous People in the Southwest United States and in Canada, and has worked with Navajo medicine people to develop training for mental health professionals with his wife, Dr. Mary Hasbah Roessel. Dr. Reinhardt is a life fellow of the APA.