Rebuilding Our Nations Through Healing Historical Trauma and Unresolved Grief - A Tribal Best Practice

1. � Maria Yellow Horse Brave Heart, PhD Rebuilding Our Nations Through Healing Historical Trauma and Unresolved Grief - A Tribal Best Practice Maria Yellow Horse Brave Heart, PhD President, The Takini Institute Associate Professor of Psychiatry/Director, Native American & Disparities Research mbraveheart@salud.unm.edu

2. � Maria Yellow Horse Brave Heart, PhD Omniciye Woiyaksape: Sharing Wisdom Council Project It is our way to mourn for one year when one of our relations enters the Spirit World. Tradition is to wear black while mourning our lost one, tradition is not to be happy, not to sing and dance and enjoy life�s beauty during mourning time. Tradition is to suffer with the remembering of our lost one, and to give away much of what we own and to cut our hair short�.Chief Sitting Bull was more than a relation�.He represented an entire people: our freedom, our way of life -- all that we were. And for one hundred years we as a people have mourned our great leader.

3. � Maria Yellow Horse Brave Heart, PhD Omniciye Woiyaksape We have followed tradition in our mourning. We have not been happy, have not enjoyed life�s beauty, have not danced or sung as a proud nation. We have suffered remembering our great Chief and have given away much of what was ours�. blackness has been around us for a hundred years. During this time the heartbeat of our people has been weak, and our life style has deteriorated to a devastating degree. Our people now suffer from the highest rates of unemployment, poverty, alcoholism, and suicide in the country. Traditional Hunkpapa Lakota Elders Council (Blackcloud, 1990)

4. � Maria Yellow Horse Brave Heart, PhD Intergenerational Parental Trauma I never bonded with any parental figures in my home. At seven years old, I could be gone for days at a time and no one would look for me�.I�ve never been to a boarding school....all of the abuse we�ve talked about happened in my home. If it had happened by strangers, it wouldn�t have been so bad- the sexual abuse, the neglect. Then, I could blame it all on another race�.And, yes, they [my parents] went to boarding school. A Lakota Parent in Recovery (Brave Heart, 2000, pp. 254-255)

5. � Maria Yellow Horse Brave Heart, PhD Multiple Losses and Trauma Exposure Death of five family members killed in a collision by a drunk driver on a reservation road One month earlier, death of a diabetic relative Following month, adolescent cousin�s suicide and the death of another relative from a heart attack Surviving family members include individuals who are descendants of massacre survivors & abuse in boarding schools Many community members comment that they feel they are always in a state of mourning and constantly attending funerals.

6. � Maria Yellow Horse Brave Heart, PhD Presentation Overview Historical trauma and the historical trauma response The HTUG Intervention: A Tribal Best Practice and parenting interventions Historical trauma research Celebration of Survival Dedication: to my daughter Winona Yellow Horse Brave Heart In Memory of my sister Susan Yellow Horse-Davis

7. � Maria Yellow Horse Brave Heart, PhD Cumulative, Massive Group Trauma Origins of trauma are in genocide Boarding schools compounded trauma Trauma is transferred across generations through impairment of traditional parenting skills, identification, and other complex processes Children of massacre survivors, children of boarding school survivors pass on the trauma to their descendants

8. � Maria Yellow Horse Brave Heart, PhD Historical Trauma and Unresolved Grief Historical trauma is cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma (1985-88) Historical unresolved grief accompanies that trauma (Brave Heart, 1998, 1999, 2000)

9. � Maria Yellow Horse Brave Heart, PhD Historical Trauma Response The historical trauma response (HTR) is a constellation of features in reaction to massive group trauma This response is observed among Lakota and other Native populations, Jewish Holocaust survivors and descendants, Japanese American internment camp survivors and descendants. (Brave Heart, 1998, 1999, 2000)

10. � Maria Yellow Horse Brave Heart, PhD HT Theory & Symptoms of Depression, PTSD, Complicated/Prolonged Grief Suicidal behaviors were associated with depressive disorders, PTSD, & substance abuse/dependence (LeMaster, et al., 2004) Lifetime prevalence of 44%, 86% of these having major depression, were found in Native women (mean age 29.8 years) where 41% had attended Indian boarding schools (Duran et al., 2004 AmJPH); later study (2004 ChA&N), boarding school attendance not significantly associated with PTSD but did not assess quality of experience American Indians had an adult trauma exposure rate of 62.4% to 69.8% to at least one traumatic event; a substantial proportion of these entail death of a loved one (Manson, Beals, Klein, Croy, & AI-SUPERPFP Team, 2005).

11. � Maria Yellow Horse Brave Heart, PhD HT Theory & Symptoms of Depression, PTSD, Complicated/Prolonged Grief CG/PG: sadness, separation distress including strong yearnings, longing for and preoccupation with thoughts of the deceased, and intrusive images, psychic numbness, guilt, extreme difficulty moving on with life, and a sense of the part of the self having died (Boelen & Prigerson, 2007; Shear et al., 2005). CG may also co-occur with PTSD (20-50%); prevalence unclear for American Indians/Alaska Natives. Historical unresolved grief includes these but also yearning, pining, preoccupation with thoughts of ancestors lost in massacres, loyalty to ancestors with a focus on their suffering, as if to not suffer is to not honor them, to forget them

12. � Maria Yellow Horse Brave Heart, PhD Prolonged or Complicated Grief Tribes may also be at high risk for CG related to the impact of genocide across generations and frequent deaths of attachment figures, due to high morbidity and mortality rates, & generational boarding school trauma. Rather than ambivalent relationships, some CG researchers think that close attachments may predispose CG development; AI/AN attachment styles may be closer and more intense as a cultural norm

13. � Maria Yellow Horse Brave Heart, PhD HT Theory & Symptoms of Depression, PTSD, Prolonged Grief Native mourning resolution is distinct from European American grief Loss of close relative experienced as loss of part of self, exhibited by cutting the hair Natives maintain active relationship with ancestor spirits Massive group trauma (genocide) impairs normative grief; extent & quality of losses (trauma exposure) limit time for culturally congruent mourning resolution; history of prohibition of bereavement ceremonies

14. � Maria Yellow Horse Brave Heart, PhD Historical Unresolved Grief Issues Acute grief & Wanagi Wacipi (came at a time of severe collective trauma and loss; gave the People hope) Modern acute grief & dominant culture paradigm � unhelpful reactions (funeral leave policies, discomfort with talking about grief, ambivalence about talking, withdrawal, feeling stigmatized) Wisdom of traditional mourning practices in managing acute grief Acute grief which persists becomes unresolved, prolonged, complicated Modern multiple losses & cumulative traumatic losses superimposed upon collective generational trauma

15. � Maria Yellow Horse Brave Heart, PhD The Takini (Survivor) Network is a Native non-profit organization (formed in 1992) designed to address healing from historical trauma and historical unresolved grief among the Lakota as well as other Native people through therapeutic work, prevention, research, publication and community education. The Takini Network

16. � Maria Yellow Horse Brave Heart, PhD Historical Trauma & Unresolved Grief Intervention: A Tribal Best Practice Psychoeducation about genocide, boarding school losses, & oppression Use of audiovisual materials to stimulate memories and to educate participants about the traumatic historical context Small & large group processing and in dyads (pairs); exercises Focus as well on lifespan trauma Cathartic, traditional cultural experiences

17. � Maria Yellow Horse Brave Heart, PhD Historical Trauma Intervention: Four Major Intervention Components Confronting historical trauma and embracing our history Understanding the trauma Releasing our pain Transcending the trauma

18. � Maria Yellow Horse Brave Heart, PhD HT Intervention 1st Component: Confrontation with the Past (Fogelman) � Genocide

19. � Maria Yellow Horse Brave Heart, PhD Background: Genocide Native history meets UN 1948 Geneva Convention definition of genocide Congressional genocidal policy: no further recognition of their rights to the land over which they roam; go upon said reservations�chose between this policy of the government and extermination; wards of the government, controlled and managed at its discretion BIA Education Division called �Civilization Division� Congressional policy of forced separation of children from family and tribe; militaristic Gender roles and relationships impaired by boarding schools

20. � Maria Yellow Horse Brave Heart, PhD Boarding School Era This bill provides for the utilization of vacant military posts and barracks for the industrial education of nomadic youth and the employment of officers of the army as teachers or to be otherwise detailed by the Department of War. Education as a means of civilizing and elevating the savage has ceased to be experimental. Best results are obtained with the removal of children from all tribal influence (US Congress, 1879).

21. � Maria Yellow Horse Brave Heart, PhD HT Intervention 2nd Component: Understanding the Trauma

22. � Maria Yellow Horse Brave Heart, PhD Historical Trauma Response Features  Survivor guilt Depression Sometimes PTSD symptoms Psychic numbing Fixation to trauma Somatic (physical) symptoms Low self-esteem Victim Identity Anger Self-destructive behavior including substance abuse Suicidal ideation Hypervigilance Intense fear Dissociation Compensatory fantasies Poor affect (emotion) tolerance

23. � Maria Yellow Horse Brave Heart, PhD Historical Trauma Response Features Death identity � fantasies of reunification with the deceased; cheated death Preoccupation with trauma, with death Dreams of massacres, historical trauma content Loyalty to ancestral suffering & the deceased Internalization of ancestral suffering Vitality in own life seen as a betrayal to ancestors who suffered so much

24. � Maria Yellow Horse Brave Heart, PhD Intergenerational Traumatic Grief Federal prohibition against practice of traditional Native spirituality limited bereavement resulting in unresolved grief across generations Dominant societal view of Natives as �savage� and unfeeling � dehumanizing, invalidating grief Acute grief which persists becomes unresolved, prolonged, complicated Modern multiple losses & cumulative traumatic losses superimposed upon collective generational trauma

25. � Maria Yellow Horse Brave Heart, PhD Yehuda (1999) Vulnerability among children of Holocaust survivors for the development of PTSD COS had greater degree of cumulative lifetime stress yet no differences in degree of trauma exposure (self-report) Offspring perceive or experience events as more traumatic and stressful COS with chronic PTSD parent more likely to develop PTSD Parental trauma symptoms are the critical risk factors COS trauma responses Lifetime and current PTSD was significantly higher among Holocaust descendants

26. � Maria Yellow Horse Brave Heart, PhD Identification & Self-Hatred Identification with the aggressor (A. Freud) & internalized oppression (Freire) Identification with the oppressor�s view of Native women, resulting in self-hatred Passing self-hatred onto daughters Self-destructive behavior (i.e. SA) to avoid pain and to act out the self-hatred Identifying with parents� trauma response patterns

27. � Maria Yellow Horse Brave Heart, PhD Impact Upon Indian Parenting Many boarding school survivor parents report traumatic, negative experiences including physical & sexual abuse Boarding school survivor parents report a sense of self as being wounded and impaired in their competence as parents Descendants of boarding school survivors frequently report abuse and/or neglect in their own childhoods.

28. � Maria Yellow Horse Brave Heart, PhD More HT Impact on Parents Generational psychological impairment � boarding school message was that our cultures are inferior and we are not capable of raising our own children Traditional gender roles and relationships impaired � women & children were never the property of men, DV not tolerated; sacredness of women & children lost, both women and men lost traditional parenting roles; men lost roles of warriors and protectors

29. � Maria Yellow Horse Brave Heart, PhD Historical Trauma�s Impact upon Health: Diabetes & Other Diseases The Release of Stress Hormones such as cortisol and its impact upon the body, upon memory and cognitive functions Cortisol leads to increased, impaired sleep Long-term elevated adrenalin wears out internal organs � heightened state of alertness (hypervigilance, anxiety) Comorbidity of depression and PTSD with coronary heart disease; Stress hormones may interfere with use of insulin in Type 2 Diabetes

30. � Maria Yellow Horse Brave Heart, PhD HT Intervention 3rd Component: Releasing Our Pain

31. � Maria Yellow Horse Brave Heart, PhD Traditional Protective Factors: Woope Sakowin(7 Laws of the Lakota) Wacante Ognake - Generosity Wowaunsila � Compassion Wowayuonihan � Respect Wowacin Tanka - To Have a Great Mind Wowahwala � Humility, State of Silence, To be humble Woohitike � Courage, Bravery, Principal, Discipline Woksape � Wisdom, Understanding

32. � Maria Yellow Horse Brave Heart, PhD Historical Trauma Intervention Research & Evaluation (1992 - 2003) Reduction in sense of feeling responsible to undo painful historical past Less shame, stigma, anger, sadness Decrease in guilt Increase in joy Improved valuation of true self and of tribe Increased sense of personal power

33. � Maria Yellow Horse Brave Heart, PhD HT Intervention 4th Component: Transcending the Trauma

34. � Maria Yellow Horse Brave Heart, PhD Transcending the Trauma Healing the Next Seven Generations Incorporating our ceremonies in the healing process More Native research on HT and HT interventions Collaborating and learning from other massively traumatized groups Our historical trauma, including individual current and lifespan trauma, must be acknowledged and validated

35. � Maria Yellow Horse Brave Heart, PhD The First HT Intervention1992 Quasi-experimental study, 45 Lakota, on effectiveness of group intervention on collective group trauma & grief Traditional culture & ceremonies throughout facilitated cathartic release of emotions Psychoeducation; narratives & trauma testimony Delivered over 4 days; random assignment to small process groups with the trained Native facilitators

36. � Maria Yellow Horse Brave Heart, PhD Return to the Sacred Path Study Mean age of study population was 43 72.1% attended boarding school; mean age 8.9 years; 38.7% attended before 6 yrs, 48.4% before 7 yrs; mean distance from home 123.1 mi, mode 300 miles Physical abuse (58.1%) & sexual abuse (22.6%) by staff 90.7% reported parental boarding school attendance 50% reported death of a close relative in past year, 100% in the past two years Statistically significant differences on all scales of projective measures

37. � Maria Yellow Horse Brave Heart, PhD Changes on the Lakota GEQ [Statistical significance achieved for 7 items including these (Brave Heart, 1995, 1998)]

38. � Maria Yellow Horse Brave Heart, PhD Semantic Differential Results: Changes Over Time Evaluation Scale My True Self (P=.004, p<.01) Anger (P=.032, p<.05) The Past (P=.004, p<.01) Wasicu (P=.001, p<.01)

39. � Maria Yellow Horse Brave Heart, PhD Semantic Differential Results: Changes Over Time Potency Scale - My True Self (P=.035, p<.05) - Wasicu (P=.002, p<.01) - The American Indian Holocaust (P=.000, p<.0001)

40. � Maria Yellow Horse Brave Heart, PhD Semantic Differential Results: Changes Over Time Activity Scale - The American Indian Holocaust (P=.012, p<.05) - The Past (P=.001, p<.01) - My People (P=.006, p<.01)

41. � Maria Yellow Horse Brave Heart, PhD Table 11: Gender Differences for Affects Experienced Often Before, During and After the Intervention

42. Maria Yellow Horse Brave Heart, PhD Gender Differences: Boarding School Experiences Experiences %Men %Women Attended boarding school 82.4% 65.4% Hit at boarding school 85.7% 35.3% Punished for speaking 57.1% 20.0% Racism in boarding school 85.7% 58.8% Sexually abused at school 28.6% 17.7% (Brave Heart, 1999. Gender differences in the historical trauma response, J of Health & Social Policy, 10(4), 1-21)

43. Maria Yellow Horse Brave Heart, PhD Wakanheja (Sacred Children) Lakota Parenting Curriculum Content includes emphasis on traditional values, traditional parenting styles (pre-boarding school days) & traditional protective factors Includes review of risk & protective factors for effective parenting Includes the Historical Trauma & Unresolved Grief Intervention key components (HTUG) Includes the Woope Sakowin (Seven Laws) as a guide for parenting & effective parenting skills

44. � Maria Yellow Horse Brave Heart, PhD Taking Care of the Nation: The Traditional Meaning of Native Parenting Taking care of the Nation Sacred responsibility We don�t own our children Children are placed at the center of the Nation Need to rebuild our Nation Children may be old spirits returning to earth and have wisdom

45. � Maria Yellow Horse Brave Heart, PhD Oyate Ptayela Article (1999) Qualitative study of Lakota parenting model Parents, most boarding school survivors or descendants of survivors, expressed feelings of being inadequate & overwhelmed Boarding schools and other historical traumas have impaired traditional cultural ways for parenting Traditional ways had protective factors and place the sacred child at the center of the nation & child abuse and neglect were not tolerated

46. � Maria Yellow Horse Brave Heart, PhD Oyate Ptayela: Risk Factors Ineffective or destructive parenting includes: Authoritarian & inconsistent responses to children Lack of nurturing, criticalness, insensitivity to child�s needs Poor bonding with parents & lack of maternal involvement [I would add paternal as well] Family norms permitting alcohol USE, along with these other risk factors for alcoholism or drug abuse [as well as seen for juvenile delinquency] (Hawkins, Catalano, & Miller, 1992)

47. � Maria Yellow Horse Brave Heart, PhD Oyate Ptayela: Protective Factors Effective parenting includes: High parental acceptance of child, consistency [including keeping your promises, doing what you say, and consistency in discipline] Moderate to high restrictiveness [without being harsh or �hollering around�] Nurturing, sensitivity to child�s needs High positive parental involvement with child Strong attachment, bonding with family & social groups that value NON-USE of substances/alcohol (Hawkins, Catalano, & Miller, 1992)

48. � Maria Yellow Horse Brave Heart, PhD Oyate Ptayela: Protective Factors Effective parenting includes: Firm discipline coupled with nurturing Family & social support for child Regular �religious� involvement (Hawkins, Catalano, & Miller, 1992) Traditional parenting had protective factors; oral histories attest to love & affection in the home before boarding school attendance in 1940s & in some cases more recently Boarding school style discipline has replaced many of these practices

49. � Maria Yellow Horse Brave Heart, PhD Themes from Qualitative Evaluation of Parental Responses (1996-1998) Increased sense of parental competence Increase in use of traditional language Increased communication with own parents and grandparents about HT Improved relationships with children, parents, grandparents, and extended kinship network Increased pride in being Lakota and valuing own culture, i.e. Seven Laws

50. � Maria Yellow Horse Brave Heart, PhD Transcending the Trauma Healing the Next Seven Generations Incorporating our ceremonies in the healing process Developing Native research on HT and HT interventions Collaborating and learning from other massively traumatized groups Our historical trauma, including individual current and lifespan trauma, must be acknowledged and validated

51. � Maria Yellow Horse Brave Heart, PhD Indigenous Driven Research: Direct Descendants of HT Event Community sample of 486 urban AI/AN adults Direct descendants (DD) had higher perceived mental health problems, depression, PTSD, alcohol/drug problems, thought more about collective HT, followed by Don�t Knows (DK); Chi square showed significant differences DD had greater guilt and feeling responsible to undo pain of past collective trauma, followed by DK DD were more proud, more Native language comprehension, practiced traditional spirituality more, and felt more connected

52. � Maria Yellow Horse Brave Heart, PhD Direct Descendants of HT Event in Western Urban Sample Limitations � preliminary data � logistic regression analysis in process Implications � DD may also have come from more traditional family lineage and those who were �hostiles� � who resisted the cavalry DD may have had more trauma exposure and higher degree of Indian blood/more full-blood phenotype (skin color and features); could be older (checking) DK interesting � something about no knowing that is emotionally challenging Tribal differences suggested; some tribes may have had greater or more recent HT exposure, more DD in specific tribes; cultural differences in coping and grief resolutions

53. � Maria Yellow Horse Brave Heart, PhD Direct Descendants of HT Event in Western Urban Sample Trauma of boarding schools among direct descendants could have resulted in �fight� rather than �flight� � defiance, holding onto the language (oral testimony of refusal to cry during a beating) Admission of perceived mental health problem, including alcoholism, may be related to less stigma with sobriety movement and also participation in traditional ceremonies where cathartic release and openness are the norms; ceremonies role-model affect tolerance and expression (Brave Heart, Elkins, Carliner, in preparation)

54. � Maria Yellow Horse Brave Heart, PhD Recommendations for Adapting HTUG & Developing More Tribal Best Practices Review literature on Historical Loss Scale and Historical Loss Associated Symptoms Scale (Whitbeck, et al., 2004), Jervis et al. (2006) examining historical consciousness, attitudes about its importance, and their association with Indian identity, Walters (2004) inclusion of microaggressions; colonial trauma response (HTR) Current work underway on the Indigenous Peoples survey � includes structured measures for PTSD assessment as well as HT items (Brave Heart) Identify collective tribal historically traumatic events Develop audiovisual materials for psychoeducation on the trauma

55. � Maria Yellow Horse Brave Heart, PhD Indigenous Peoples of the Americas Survey (IPS) HT and HTR questions; identity; collective trauma and grief; PTSD; depression and other health/mental health issues; ; social support; experiences of racism and discrimination; standardized measures and original questions Sections for Indigenous Peoples from US & Canada; section for Indigenous Peoples from Mexico, Central, and South America

56. � Maria Yellow Horse Brave Heart, PhD Wakiksuyapi Responses Carry the trauma for the family, extended kin, and Nation Survivor guilt Trauma fixation Loyalty to ancestors Vitality in own life seen as betrayal Compensatory fantasies � trying to undo the past

57. � Maria Yellow Horse Brave Heart, PhD Wakiksuyapi (Memorial People) Inspired by Wardi�s work Memorial Candles In Holocaust families, one person is selected to carry the trauma for the family For example, for the Lakota, specific tiospaye (extended kinship network) or bands may carry the trauma for the Nation, i.e. those most impacted by Wounded Knee Massacre

58. � Maria Yellow Horse Brave Heart, PhD Celebration of Survival Video Presentation: A Celebration of Survival: The Takini Network (supported by CSAT) includes historic boarding school slides summarizes historical trauma intervention theory and approach describes historic 2001 Models for Healing Indigenous Survivors Conference Follow up conferences held in 2003 and 2004

59. � Maria Yellow Horse Brave Heart, PhD Website www.historicaltrauma.com Developed by Raymond Daw (Dine�)

60. � Maria Yellow Horse Brave Heart, PhD References Brave Heart, M.Y.H., DeBruyn, L.M., Crazy Thunder, D., Rodriguez, B., & Grube, K. (2005). . This is hallowed ground: Native Voices From Ground Zero, In Danieli, Y. & Dingman, R. (Eds) On the Ground After September 11: Mental Health Responses and Practical Knowledge Gained. New York: Haworth Press. Brave Heart, M.Y.H. (2003) The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: A Lakota Illustration, Journal of Psychoactive Drugs, 35 (1), 7-13. Brave Heart, MYH (1998). The return to the sacred path: Healing the historical trauma response among the Lakota. Smith College Studies in Social Work, 68(3), 287-305

61. � Maria Yellow Horse Brave Heart, PhD References Brave Heart, M.Y.H. (1999) Oyate Ptayela: Rebuilding the Lakota Nation through addressing historical trauma among Lakota parents. Journal of Human Behavior and the Social Environment, 2(1/2), 109-126. Brave Heart, M.Y.H. (2000) Wakiksuyapi: Carrying the historical trauma of the Lakota. Tulane Studies in Social Welfare, 21-22, 245-266. Brave Heart, M.Y.H. (2001) Clinical assessment with American Indians. In R.Fong & S. Furuto (Eds), Cultural competent social work practice: Practice skills, interventions, and evaluation (pp. 163-177). Reading, MA: Longman Publishers. Brave Heart, M.Y.H. (2001) Clinical interventions with American Indians. In R. Fong & S. Furuto (Eds). Cultural competent social work practice: Practice skills, interventions, and evaluation (pp. 285-298). Reading, MA: Longman Publishers.

62. � Maria Yellow Horse Brave Heart, PhD References Beals, J., Manson, S., Whitesell, N. Spicer, P., Novins, D. & Mitchell, C. (2005). Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Archives of General Psychiatry, 162, 99-108. Beristain, C., Paez, D. & Gonzalez, J. (2000). Rituals, social sharing, silence, emotions and collective memory claims in the case of the Guatemalan genocide. Psicothema, 12(Supl.), 117-130. Duran, BM, Sanders, M, Skipper, B, Waitzkin, H, Malcoe, LH, Paine, S, & Yager, J. (2004). Prevalence & correlates of mental disorders among Native American women in primary care. American Journal of Public Health, 94(1), 71-77. Huang, B., Grant, BF., Dawson, DA.,Stinson, FS., Chou, SP, Saha, TD, Goldstein, RB, Smith, S.M. , Ruan, WJ, & Pickering, RP. (2006). Race-ethnicity & the prevalence & co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and Axis I and II disorders: United States, 2001 to 2002. Comprehensive Psychiatry, 47, 252-257.

63. � Maria Yellow Horse Brave Heart, PhD References Indian Health Service (2001). Trends in Indian Health 2000-2001. Washington, DC: U.S. Department of Health & Human Services. Legters, L.H. (1988). The American genocide. Policy Studies Journal, 16 (4), 768-777. Lewis-Fernandez, R. & Diaz, N. (2002). The cultural formulation: A method for assessing cultural factors affecting the clinical encounter. Psychiatric Quarterly, 73(4), 271-295. Manson, S., Beals, J., O�Nell, T., Piasecki, J., Bechtold, D., Keane, E., & Jones, M. (1996). Wounded spirits, ailing hearts: PTSD and related disorders among American Indians. In A. Marsella, M. Friedman, E. Gerrity, & R. Scurfield (Eds), Ethnocultural aspects of Posttraumatic Stress Disorder (pp. 255-283). Washington DC: American Psychological Association. Robin, R.W., Chester, B., & Goldman, D. (1996). Cumulative trauma and PTSD in American Indian communities (pp. 239-253). In Marsella, A.J., Friedman, M.J., Gerrity, E.T., & Scurfield, R.M. (Eds), Ethnocultural aspects of Post-traumatic Stress Disorder. Washington, DC: American Psychological Press

64. � Maria Yellow Horse Brave Heart, PhD References Robin, R., Chester, B., Rasmussen, J., Jaranson, J. & Goldman, D. (1997). Prevalence and characteristics of trauma and posttraumatic stress disorder in a southwestern American Indian community. American Journal of Psychiatry, 154(11), 1582�1588. Shear, K., Frank, E., Houck, P.R., and Reynolds, C.F. Treatment of complicated grief: A randomized controlled trial, 2005, JAMA, 293 (21), 2601-2608. US Senate Miscellaneous Document, #1, 40th Congress, 2nd Session, 1868, [1319]

65. � Maria Yellow Horse Brave Heart, PhD References Brave Heart, M.Y.H. (1999) Gender differences in the historical trauma response among the Lakota. Journal of Health and Social Policy, 10(4), 1-21. Brave Heart, M.Y.H. & Spicer, P. (1999). The sociocultural context of American Indian Infant Mental Health. World Association of Infant Mental Health Handbook of Infant Mental Health. J.D. Osofsky & H.E. Fitzgerald (Eds.). John Wiley & Sons. Brave Heart, M.Y.H., & De Bruyn, L. (1998). The American holocaust: Historical unresolved grief among native American Indians. National Center for American Indian and Alaska Native Mental Health Research Journal, 8(2), 56-78.