Historical trauma among indigenous peoples of the Americas: concepts, research, and clinical considerations.
Article Type: Report
Subject: Mental health (Research)
Racism (Influence)
Racism (Psychological aspects)
Indigenous peoples (Psychological aspects)
Psychic trauma (Demographic aspects)
Psychic trauma (Surveys)
Authors: Heart, Maria Yellow Horse Brave
Chase, Josephine
Elkins, Jennifer
Altschul, Deborah B.
Pub Date: 10/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Oct-Dec, 2011 Source Volume: 43 Source Issue: 4
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 278880914
Full Text: Abstract--Indigenous Peoples of the Americas have experienced devastating collective, intergenerational massive group trauma and compounding discrimination, racism, and oppression. There is increasing evidence of emotional responses to collective trauma and losses among Indigenous Peoples, which may help to inform ways of alleviating psychological suffering and unresolved grief. Tribal cultural and regional differences exist which may impact how the wounding across generations and within an individual's lifespan are experienced and addressed. This article will review the conceptual framework of historical trauma, current efforts to measure the impact of historical trauma upon emotional distress, and research as well as clinical innovations aimed at addressing historical trauma among American Indians/Alaska Natives and other Indigenous Peoples of the Americas. We will discuss assessment of historical trauma and implications for research and clinical as well as community interventions, and conclude with recommendations.

Keywords--American Indians, grief, historical trauma, Indigenous Peoples, mental health

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Indigenous Peoples of the Americas (1) are a diverse population, with over 500 federally recognized tribes in the United States and over 400 in Latin America. Indigenous Peoples have experienced pervasive and cataclysmic collective, intergenerational massive group trauma and compounding discrimination, racism, and oppression. There is insufficient data on emotional responses to collective trauma and losses among Indigenous Peoples and how best to intervene in order to alleviate psychological suffering and unresolved grief. A long-term goal of historical trauma intervention practice is to reduce emotional suffering among Indigenous Peoples of the Americas by developing culturally responsive interventions driven by the community to improve behavioral health.

American Indians and Alaska Natives (2) are one segment of the Indigenous Peoples of the Americas. American Indians/Alaska Natives rank higher in health disparities than any other racial or ethnic group in the United States. American Indians face emotional challenges such as depression, substance abuse, collective trauma exposure, interpersonal losses and unresolved grief, and related problems within the lifespan and across generations (Beals et al. 2005; Manson et al. 2005, 1996; Whitbeck et al. 2004a, b; Brave Heart 2003, 1998). Although there is a paucity of research among Indigenous Peoples living within the United States, some studies indicate elevated levels of PTSD and depression among both American Indians and Alaska Natives (Manson et al. 2005) and Indigenous Peoples from Latin America (Sabin et al. 2003). In addition, substance abuse is a significant problem (Wakers 2004), with death from alcohol-related causes being five times more likely for American Indians than for White Americans. Additionally, suicide rates are 50% higher than the national average (US DHHS 2001). Thus, there is an urgent need to reduce racial and ethnic health disparities, which have a significant public health impact, through designing effective interventions with American Indians/Alaska Natives (Wallerstein & Duran 2010). In order to develop culturally resonant interventions for Indigenous Peoples, more information is needed regarding collective as well as individual lifespan trauma, grief, and loss in this diverse population who have faced histories of genocide, colonization, forced assimilation, and exclusion that undermine intergenerational health and well-being.

Despite the array of tribal cultural practices, many Indigenous Peoples share historical and contemporary experiences, intertribal organizations, and often congruent worldviews and values. With increasing migration to urban areas, approximately 60% of American Indians live in cities rather than on reservations (US Census Bureau 2006). Trauma among American Indians/Alaska Natives is pervasive, often related to the mass genocide documented in the literature (Jaimes 1992; Stannard 1992; Hoxie 1989; Legters 1988; Thornton 1987; Prucha 1984; Tanner 1982; Brown 1970). The subsequent communal suffering, cumulative trauma, and prevalence of PTSD in some American Indian communities have been addressed by a few studies and clinical articles (Beals et al. 2005; Manson et al. 2005, 1996; Robin et al. 1997a, b; Robin, Chester & Goldman 1996). For instance, Whitbeck and colleagues (2004a) found evidence of the impact of historical loss on risks for alcohol abuse among American Indians. The collective traumatic past of American Indians and Alaska Natives and subsequent responses merit consideration in the design and delivery of clinical interventions and research with these populations. Although alcohol remains the most prevalent substance abused by American Indians/Alaska Natives, there is increasing abuse of drugs such as methamphetamines, IV drug use and risks of needle sharing resulting in devastating illnesses such as HIV/AIDS and hepatitis C. Thus, there is a need to target all substance abuse prevention and early intervention efforts for this population.

This article will review the conceptual framework of historical trauma, current efforts to measure the impact of historical trauma upon emotional distress, and research as well as clinical innovations aimed at addressing historical trauma among American Indians/Alaska Natives and other Indigenous Peoples of the Americas. We will discuss assessment of historical trauma and implications for research and clinical as well as community interventions, and conclude with recommendations.

CONCEPTUAL FRAMEWORK OF HISTORICAL TRAUMA AND HISTORICAL TRAUMA RESPONSE

Primm and colleagues (2010) note the importance of taking a public health approach to addressing mental health disparities for racial/ethnic minorities, specifically examining the prevalence rates, diagnoses, access to care and sources of care. Collective, communal, and generational trauma for massively traumatized Indigenous Peoples, as well as ongoing racism, oppression, and discrimination, have been described in the literature in relation to their impact on the prevalence of psychiatric disorders among American Indians/Alaska Natives (Duran & Walters 2004; Duran et al. 1998). Elevated chronic trauma exposure and the high prevalence of DSM IV-TR disorders (including both mental health and substance abuse disorders) have been found among large samples of American Indian adults living on reservations (Beals et al. 2005; Manson et al. 2005; Robin et al. 1997a, b).

Historical trauma (HT) is defined as cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma (Brave Heart 2003, 1998). To our knowledge, the concept of historical trauma among American Indians first appeared in the clinical literature in 1995 (Brave Heart 1998). Historical trauma theory frames lifespan trauma in the collective, historical context, which empowers Indigenous survivors of both communal and individual trauma by reducing the sense of stigma and isolation. Historical loss is a term utilized by Whitbeck and colleagues (2004a) in a measure of historical trauma.

The historical trauma response (HTR) has been conceptualized as a constellation of features associated with a reaction to massive group trauma. Historical unresolved grief, a component of this response, is the profound unsettled bereavement resulting from cumulative devastating losses, compounded by the prohibition and interruption of Indigenous burial practices and ceremonies. Whitbeck and colleagues (2004a) found that thinking about historical trauma is associated with emotional distress, specifically depression and anger. These researchers raised additional important questions for consideration such as: what are the psychological characteristics of people with high levels of perceived loss and what tribal differences contribute to responses to historical trauma. Further considerations include diversity in responses related to being a direct descendant of a historically traumatic event or more recent collective trauma. For example, some boarding schools were reportedly more traumatic and attendance was more widespread in some tribal communities. Additionally there may be regional and cultural tribal factors that impact the magnitude of historically traumatic events and responses to them (e.g., there are some regions where tribes may currently be experiencing higher degrees of discrimination and oppression and there is a need to understand how this impacts HTR). Thus, studies are needed to determine the prevalence of HTR and the diversity among tribal groups regarding historical trauma exposure. There has been a groundswell of positive reactions to the concept of historical trauma (Whitbeck et al. 2004a) as evidenced by significant requests for workshops and training on this topic across tribes throughout the United States and Canada, the number of "hits" on the website www.historicaltrauma.com, an increase in literature on this topic, and local as well as national and international conferences about historical trauma and related topic areas. Research is needed about the prevalence and characteristics of HTR as well as the effectiveness of the HT intervention strategies now in use.

RELATIONSHIP OF CURRENT BEREAVEMENT AND HISTORICAL TRAUMA: CLINICAL IMPLICATIONS

Many Indigenous communities experience multiple traumatic deaths with great frequency due to elevated morbidity and mortality rates, lowered life expectancy, and high accidental death rates. Most grief research focuses on marital bereavement (Sanders 1989) rather than the extensive premature and traumatic losses faced by Indigenous Peoples. Brave Heart's conceptual model is that HT and HTR are strongly related to the experience of lifetime traumatic events and that both are related to a series of psychological outcomes for individuals including unresolved grief, complicated/prolonged grief, PTSD and depression, all of which are often comorbid with substance abuse. The major mechanisms for ameliorating these results include developing functional support systems and returning the individual to a sacred path as defined by their particular tribal culture. The hope is to demonstrate that this relationship exists and then develop interventions to alter functional support systems and increase the individual's participation in traditional culture. The eventual outcome will be reductions in behavioral health consequences.

Traditional American Indian/Alaska Native mourning practices and cultural protective factors were impaired due to the federal prohibition around 1883 against the practice of traditional ceremonies, which lasted until the 1978 American Indian Religious Freedom Act. However, parts of Indigenous practices related to traditional burials are still not permitted. Importantly, when members of Indigenous communities experience death of close attachment figures, the intense positive attachment to the deceased may be a risk factor for complicated or prolonged grief (Shear et al. 2011). For American Indian/Alaska Natives, the quality and intensity of interpersonal attachment is of great importance for conceptualizing Indigenous bereavement and providing effective strategies for coping with loss not only in the lifespan but across generations. For example, a tradition in some tribal groups is to cut the hair when a close relative dies, a manifestation of the degree of attachment and a sense of a loss of part of oneself. Addressing grief and loss must incorporate an understanding of traditional normative grief resolution along with modern practices within each tribal community.

The degree of interpersonal losses and trauma exposure in a number of American Indian/Alaska Native communities has been documented (Manson et al. 2005). More research is needed regarding the relationship between this trauma exposure and risk factors for PTSD, prolonged grief, substance abuse, and depression, to elucidate some of these relationships and to facilitate development of interventions to address root causes of behavioral health needs. To date, interventions that reframe symptoms in terms of collective responses have been observed to alleviate a number of the symptoms at least on a short-term basis (Brave Heart 2003, 1998). Such interventions also focus on the cumulative generational impact of compulsory Indian boarding schools which may negatively influence the quality of parental interaction with children, and contribute to unresolved or prolonged grief, depression, substance abuse, and other behavioral health issues (Whitbeck et al. 2004b; Brave Heart 2003, 1998). Addressing parental trauma and generational boarding school issues for parents may help to improve parenting skills and reduce behavioral health risks for children.

Relationship Between PTSD, Depression and Historical Trauma

In their studies on PTSD among a Southwestern tribe, Robin, Chester and Goldman (1996) asserted the need to describe the collective and communal trauma of American Indians related to the historical past and ongoing impact of oppression and racism. Manson and colleagues (1996) posit that American Indian youth may demonstrate higher thresholds for trauma and PTSD due to chronic and severe trauma exposure, cultural manifestations of trauma responses that may be different, and/or PTSD assessment instruments that may be biased. Although this study found a lower prevalence of PTSD than expected for American Indian boarding school adolescents, other studies have found elevated rates of PTSD among American Indians (Beals et al. 2005).

The original intent of HT was to frame current trauma exposure within the context of historical trauma to reduce stigma about emotional distress and responses to individual trauma, as well as highlight intergenerational collective trauma. The intent of HT and HTR is to foster healing by providing a context for the extreme emotional distress found in American Indian and Alaskan Native communities.

HISTORICAL TRAUMA MEASURES TO INFORM CLINICAL AND COMMUNITY-BASED PRACTICES

Whitbeck and colleagues (2004a) developed the Historical Loss Scale (HLS) and the Historical Loss and Associated Symptoms Scale (HLAS) and moved the field forward in terms of empirical evidence demonstrating a link between the trauma of a collective historical past and the emotional experiences of the HTR, compounded by lifespan trauma. HLS assesses the frequency with which people think about the historically traumatic events and losses, and HLAS is designed to capture emotional responses to these losses. Whitbeck and colleagues (2004a) found that the higher the score was for perceived historical loss, the more likely was the report of depression and anger associated with the thoughts about that historical loss. Broader use of HLS and HLAS with different tribal groups would increase our knowledge of the prevalence of HT consciousness and HTR among American Indians/Alaska Natives.

Moving Research Forward: Development of the Indigenous Peoples of the Americas Survey

The collective, intergenerational massive group trauma and compounding discrimination, racism, and oppression among American Indians (Whitbeck et al. 2002) as well as unresolved grief and loss (Whitbeck et al. 2004a; Brave Heart 1998) are increasingly a focus of attention in the literature, in the field, and in tribal communities. Whitbeck and colleagues (2004b) examined the impact of discrimination on the collective issues facing a northern Midwest reservation group and identified that perceived historical loss affected American Indian adolescent depression in that tribal community (Whitbeck et al. 2011). Importantly, neither the HLS nor the HLAS include a full measure of depressive symptoms or PTSD. Additionally, the HLS and HLAS both examine perceived loss of family ties as a consequence of boarding schools but do not ask the individual respondent about their own specific boarding school trauma or particular family history related to boarding school attendance. Research would be strengthened by adding these areas.

In the Return to the Sacred Path intervention (Brave Heart 1998), the first Historical Trauma and Unresolved Grief Intervention (HTUG), information was collected from participants regarding their own boarding school attendance, generational boarding school family history, and rating of the quality of these experiences. Additional questions included the distance of the boarding school from the home tribal community and the frequency of visits home per year as well as traumatic experiences such as physical and sexual abuse at the school. Such information was useful in helping participants to process their traumatic experiences within the historical collective context and experience cathartic relief and support. In clinically informed intervention research, more specific questions may facilitate increased tailoring of healing approaches.

Indigenous Peoples of the Americas Survey

The Indigenous Peoples of the Americas Survey (IPS) is an instrument in development, which is designed to inform clinical practice and research on the effectiveness of interventions incorporating historical trauma and unresolved grief. It is also intended to explore tribal diversity in the experiences of HT and HTR so that healing can be tailored to fit a variety of tribal communities. IPS is an effort to fill some of the gaps and answer some of the questions raised in previous sections of this article. With service providers in mind and the kind of information needed for clinical intervention, treatment, and counseling, the IPS consolidates other structured measures and assessment tools into a survey (giving credit to and citing these measures), including the HLS and HLAS, and also adds items that provide more detail about tribal identity, traumatic experiences, depressive symptoms, PTSD symptoms, and Indigenous identity. Further, the IPS asks for more detailed trauma history (both lifespan and collective historical trauma), looks at tribal similarities and differences in the experience, and may be useful in clinical settings for treatment planning and intervention. IPS will also provide a better sense of the prevalence of HTR and symptoms across multiple tribal populations. Identifying constructs that may be generalizable to numerous tribal groups would be helpful in informing the design of culturally responsive clinical practice for this traditionally underserved population. The authors, as clinicians and clinical and services researchers in tribal communities, are concerned with the application of HT concepts to intervention work. The IPS asks about specific losses the individual has experienced themselves as well as the collective past and unresolved, prolonged grief.

IPS will also provide preliminary data on the nature and prevalence of the emotional challenges (depression, collective trauma exposure, interpersonal losses, and unresolved grief) facing Indigenous parents, which is useful in informing the development of an intervention designed to improve behavioral well-being, parental competence, and relationships with children. Earlier versions of the IPS were reviewed by Indigenous clinical graduate students and Indigenous providers. Currently, the IPS is in the process of review by an Indigenous advisory panel and will be piloted and then refined. Preliminary development of the IPS was grounded in prior work, including a qualitative study on the experience of HT and manifestations of HTR (Brave Heart 2000).

The precedent for designing the IPS was to examine collective trauma and commonalities, while simultaneously respecting diversity among Indigenous Peoples across the Americas. This precedent emerged from an orientation that we are relatives, and is consistent with a variety of Indigenous organizations that have developed linkages across the Canada-United States border and extended into Mexico, and Central and South America. These associations include the International Indian Treaty Council and the Inter-American Indian Institute in Mexico City, as well as global Indigenous organizations and conferences, (e.g. the Healing Our Spirit Worldwide Conference, and the United Nations Permanent Forum on Indigenous Issues).

In addition to the work of the National Aboriginal Health Organization in Canada on residential (boarding) school trauma, there has been some research on Indigenous Peoples of Latin American related to historical trauma, including the impact of unresolved grief, collective trauma, and behavioral health issues among Maya survivors and descendants of genocide in Guatemala and parts of Mexico (Sabin et al. 2003; Beristain, Paez & Gonzalez 2000). There is a need for further study to inform interventions with these underserved Indigenous populations (Gone & Alcantara 2007). Similarly, Maya Indians from Guatemala and Chiapas in Mexico have been found to suffer from collective and ongoing trauma and prolonged grief symptoms (Sabin et al. 2003; Beristain, Paez & Gonzalez 2000). The IPS will contribute to increased knowledge across Indigenous communities and the sharing of clinical healing approaches.

THE HISTORICAL TRAUMA AND UNRESOLVED GRIEF INTERVENTION

Historical Trauma and Unresolved Grief Intervention (HTUG) is a short-term, culturally congruent intervention for grief resolution and trauma mastery that has been shown to be effective among a small segment of the American Indian population with elevated psychosocial issues (Brave Heart 1998). Measures include an experimental Lakota Grief Experience Questionnaire (LGEQ) and an instrument exploring respondent's traumatic experiences including boarding school attendance and a self-report assessment of that experience, as well as projective measures. HTUG was selected as a Tribal Best Practice in 2009 by First Nations Behavioral Health Association and the Substance Abuse and Mental Health Services Administration (SAMHSA), and has been incorporated as part of a Lakota parenting prevention intervention and used with Lakota parents on the reservation (Brave Heart 1999b). Qualitative results revealed that self-perceptions of competency in parenting increased after the intervention as did improved relationships with children, parents, grandparents, and extended kinship networks. Increased use of traditional language and enhanced valuing of the tribal culture were also found in this study. The intervention was structured around the view that parents are wounded by HT, specifically the generational impact of boarding schools. Thus, parents need support to address their own trauma before being emotionally present for their children and being able to absorb parenting skill training.

HTUG has been utilized primarily with reservation-based American Indians/Alaska Natives across the U.S. and Canada but little work has been evaluated with urban communities or with Indigenous Peoples of Latin America. The intent of the IPS is to collect data on multiple tribal communities in both reservation and urban settings in order to increase further understanding of the impact of collective group trauma and lifespan trauma exposure on behavioral health symptoms, and to inform culturally responsive interventions with greater scientific rigor. A modification of the Harvard Trauma Questionnaire (HTQ) has been utilized with Maya genocide survivors, including translation into local Spanish dialect and Maya (Sabin et al. 2003). The HTQ items are incorporated into the IPS.

To our knowledge, the only intervention study reported in the literature that specifically focuses on the HTR among an Indigenous population in the United States was a study of the Historical Trauma and Unresolved Grief Intervention (Brave Heart 1999a, b, 1998). However, a number of prevention studies incorporate some consideration of HT in the intervention design. For instance, one tribal-specific prevention intervention includes culturally specific assessment, recognizes historical and cultural contextual factors, and allows for traditional healing approaches (Fisher & Ball 2002). Healing intergenerational pain is perceived as one way to prevent suicide (Strickland, Walsh & Cooper 2006) and one small qualitative study explored perceptions of effective traditional healing components among Indigenous Peoples in Canada (McCabe 2007). These studies point to the importance of incorporating HT and HTR into treatment and prevention interventions.

Incorporation of Indigenous customs and traditional healing approaches when developing interventions with Indigenous Peoples are increasingly advocated by Indigenous scholars, clinicians, and prevention specialists. Some of the tenets of Indigenous healing practices (Struthers, Eschiti & Patchell 2004) may be congruent with some methods of evidence-based treatments which could be adapted for application to diverse populations, (e.g. Interpersonal Psychotherapy; Markowitz et al. 2009). Thus, incorporation of indigenous customs and traditional healing approaches is also indicated.

CURRENT PRACTICE CONCERNS

Current Practice Concerns: Addressing Shared Experiences

Although there are tribal differences in the degree of collective generational trauma exposure there is also a similarity among Indigenous Peoples and an emphasis on shared values and traditions. Certainly tribes share a history of colonization, genocide, oppression and racism. However, some tribal groups have suffered greater numbers of traumatic events. Unifying bodies (e.g. the United Nations Permanent Forum on Indigenous Issues) conferences and associations that span across borders seek to transcend tribal differences. However, research and interventions must simultaneously respect this collective philosophy and worldview as well as tribal cultural distinctiveness and differing degrees of trauma exposure. The key to effective intervention development is to develop interventions models that may be generalizable to many tribal groups and, at the same time, adaptable for tribal cultural and historical specificity.

Although there are numerous linguistic and cultural differences within Indigenous populations there are some common cultural features that might inform intervention design, including: focus on a collectivist culture; indirect communication styles; focus on harmony and balance; shared traditional beliefs in the existence of animal spirits as guides, ancestor spirits, and feeding the spirits; and attachment to all of creation, (Brave Heart 2001 a, b; Rousseau, Morales & Foxen 2001; Beristain, Paez & Gonzalez 2000). Thus, interventions must be developed with the involvement of the Indigenous community.

Current Practice Concerns: Multilevel or Systemic Assessment

Historical trauma is a meaningful concept that resonates with Indigenous communities. There is a need for attention to communal oppression, collective trauma, and cultural distinctions in understanding and measuring trauma responses and unresolved grief (Robin, Chester & Goldman 1996; Lykes 1994; Zur 1994). While group interventions show great promise, there is also a need to develop individual and family interventions. Steps to doing this would involve gathering more exploratory data, designing interventions in partnership with Indigenous community members as consultants and advisors, testing these interventions, refining them, and then researching these interventions.

Another part of the process in alleviating the emotional suffering of Indigenous Peoples is validating the existence of not only the traumatic history but the continuing oppression. The Lakota, for instance, share the challenges of mourning mass graves, of the lack of proper burials, of massive collective traumatic losses, and of ongoing oppression and discrimination. Other tribal groups deal with traumatic histories as well (e.g., the Sand Creek Massacre of the Cheyenne, the Long Walk of the Navajo, and the Trail of Tears of the Cherokee). The United States was the last member of the United Nations to acknowledge human rights violations through the signing of the UN Declaration on the Rights of Indigenous Peoples (adopted in 2007). Official recognition of genocide is thought to be an important part of the healing process, and should be incorporated in multilevel interventions.

Evans-Campbell (2008) has articulated the need for multilevel assessment and intervention strategies to address HT at individual, family, and community levels. The interrelationship of these levels has significant implications for clinical approaches to healing. A major challenge among clinicians and researchers is the ability to not only discern detrimental effects but also identify and maximize areas of strengths and resilience.

Current Practice Concerns: Need for Family and Community Level Interventions

Boarding school attendance affected entire family systems; individual and family relationships; family, community, and cultural attachments; and interpersonal communication (Abadian 2008; Barnard 2007; Mooradian, Cross & Stutzky 2007; Grandbois 2005; Schafor, Horejsi & Horejsi 1997; Mannes 1995; Morrissette 1994). Chase (2011) found that students who experienced harsh parenting both at home and at boarding schools reported continued difficulty with trust, relationship building, parenting, and communication. Poor parenting fell on a continuum from lack of involvement to neglectful to abusive. It appears that parents who experienced harshness at boarding schools but felt loved at home were either indulgent with their own children in reaction to their own childhood experiences, or they were more balanced in their care and supervision as parents. Likewise, some students who had difficult home situations but positive experiences at boarding school had the experience of "family" with the other students and care from school staff. However, most students failed to develop appropriate nurturing and discipline skills. Clearly, clinical interventions are needed at the family level to address parenting issues that arose from the boarding school experience.

Similar to findings in earlier studies, Chase (2011) found that individuals first identify historical traumatic events, including boarding school, as important factors in the deterioration of American Indian/Alaska Native values. Earlier studies also found that individuals recognize the validity of traditional Indigenous culture and practices for a path to healing and recovery. Several researchers and practitioners have written about the consideration of intergenerational effects of historical events and historical trauma on American Indian families. For instance, with sibling groups attending boarding school together, older siblings often took on parental and protective roles for younger siblings and relatives, and this relationship continued after boarding school departure. In addition, being separated from parents and other siblings often negatively affected relations with family members when students returned home (Child 1998; Adams 1995; Hultgren & Fairbanks 1994), resulting in alienation and detachment between boarding school alumni and their home community. However, the strong bonds of kinship, the resilience of the individual students and culture most often supported the adjustment and reintegration of boarding school alumni. This was due to the fact that individuals perceived their relationships with parents and siblings to have changed during their tenure at boarding school (Chase 2011).

Future research should include the examination of the spectrum of trauma in communities, and distinguish historic events that affect individuals, families, and communities, and the array of responses to those events. Cultural groups that have experienced collective trauma, oppression, and racism are recognizing the intergenerational effects of trauma, and that healing must begin within a culturespecific context both at the family and community levels (Schafor, Horejsi & Horejsi 1997; Williams & Ellison 1996; Xuequin, Toubbeh, Cline, & Chisholm, 1998). Thus, it is important to consider culturally appropriate approaches to engaging communities and gaining community buy-in and ownership when developing interventions that can impact communities at the macro level.

CONCLUSIONS AND RECOMMENDATIONS

American Indians/Alaska Natives have experienced devastating collective, intergenerational massive group trauma and compounding discrimination, racism, and oppression. There is increasing evidence of emotional responses to collective trauma and losses among Indigenous Peoples, which may help to inform ways of alleviating psychological suffering and unresolved grief. Tribal cultural and regional differences exist which may impact how the wounding across generations and within an individual's lifespan are experienced and addressed. A long-term goal of historical trauma intervention research and practice is to reduce emotional suffering among Indigenous Peoples of the Americas by developing culturally responsive interventions driven by the community to improve the quality of life, specifically behavioral health and well-being. Our aim is to restore and empower Indigenous Peoples, to reclaim our traditional selves, our traditional knowledge, and our fight to be who we are and should be as healthy, vital, and vibrant communities, unencumbered by depression, overwhelming grief, substance abuse, and traumatic responses. In essence, we strive to transcend our collective traumatic past.

We recommend increased research on the effects of historical trauma in diverse tribal cultural regions, and that such research be driven by Indigenous Peoples and be culturally-informed. Further, we advocate for continued development and evaluation of healing intervention models, grounded in Indigenous worldviews, which aim to ameliorate the emotional distress emerging from the legacy of trauma and grief. HT and HTR appear to resonate well with communities. The next step is to determine the empirical effectiveness of related interventions in healing individuals and communities.

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NOTES

(1.) Indigenous Peoples is the term endorsed by the United Nations Permanent Forum on Indigenous Issues. For the purposes of this article, the term Indigenous Peoples of the Americas refers to the original inhabitants of the land area now known as the United States as well as Canada, Mexico, Central, and South America, and their descendants. American Indians and Alaska Natives are included in this larger collective terminology when used.

(2.) American Indian and Alaska Native are the only terms officially endorsed by the National Congress of American Indians and the National Tribal Chairman's Association.

Maria Yellow Horse Brave Heart, Ph.D. (a); Josephine Chase, Ph.D. (b); Jennifer Elkins, Ph.D. (c) & Deborah B. Altschul, Ph.D. (d)

(a) Associate Professor of Psychiatry, University of New Mexico Health Sciences Center, Center for Rural and Community Behavioral Health, Albuquerque, NM.

(b) Social Work Faculty, Oglala Lakota College, Kyle, SD.

(c) Assistant Professor, School of Social Work, University of Georgia, Athens, GA.

(d) Assistant Professor of Psychiatry, University of New Mexico Health Sciences Center, Center for Rural and Community Behavioral Health, Albuquerque, NM.

Please address correspondence to Maria Yellow Horse Brave Heart, Ph.D., Associate Professor of Psychiatry, University of New Mexico Health Sciences Center, Center for Rural and Community Behavioral Health, MSC09 5030, 1 UNM, Albuquerque, NM 87131-0001, email: MBraveHeart@salud.unm.edu.

DOI: 10.1080/02791072.2011.628913
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