1. Historical Trauma and Grief An Intervention Project Related to Place American Indigenous Research Association Salish Kootenai College, Pablo, MT October 10-11, 2014 1 Gyda Swaney, PhD 1 Ke Wu, PhD 2 Patricia A. Holkup, PhD, RN 2 Emily Matt Salois, MSW, ACSW 1 University of Montana, Missoula 2 Montana State University College of Nursing, Bozeman

2. Introduction CBPR & Indigenous research approaches Underlying issue related to health disparities  Impact of widespread grief Goals of project  Develop and pilot an intervention to address historical trauma and grief (quantitative)  Elicit a description of community members’ experiences of grief (qualitative)

3. The Intervention: A 3-Day Grief Retreat An Indigenous ceremony to honor historical trauma and grief

4. Intervention  Day 1: BELONGING  Birth/Infancy/Discovery  Introduction, virtues, telling the HT story, signs and symptoms of unresolved and disenfranchised grief.  Day 2: MASTERY  Adolescence/Faith/Personal Growth  Exploration of intergenerational/current family situations and dynamics, work on Circle of Grief (chronological identification of losses & positive lessons).  Day 3: INDEPENDENCE  Adult/Autonomy/Freedom/Recovery  Identification of relationships with the losses, letter writing exercise. Brendtro, Brokenleg, & Van Bockern, 1990; DeRoche & Malatare, 2010

5. What is the effect of the Grief Retreat on participants’ expression of grief, resilience/coping skills, psychological wellbeing, and experience of historical trauma? Grief Retreats 1-4 (N = 50, F=26; M=24) Grief Retreats 5-6 (N = 37, F=18; M=19) Table 1. Data collection schedule (Groups I – IV) Measures Pre Grief Retreat (Intervention) Post Time 1 1 st day Time 2 1 month after Demographic Grief History Questionnaire Historical Trauma Historical Loss Scale (HLS) Historical Loss Associated Symptoms Scale (HLASS) Traumatic Grief Inventory of Traumatic Grief (ITG) Table 1. Data collection schedule Measures Pre Grief Retreat (Intervention) Post Time 1 1 st day Time 2 1 day > Time 3 1 mo > Time 4 3 mo > Demographic Grief History Questionnaire Grief Question: 1.Have you experienced another death? Qualitative Questions: 1.What was helpful? 2.What do you wish was included? Historical Trauma Historical Loss Scale (HLS) Historical Loss Associated Symptom Scale (HLASS) Traumatic Grief Inventory of Traumatic Grief (ITG) Resilience/Coping Brief COPE Inventory (BC) Brief Resilience Scale (BRS) Inventory of Support Evaluation List (ISEL) Psychological Kessler-6 (K-6) Positive and Negative Affect Schedule (PANAS) Approximate time to complete the packet 50 min35 min40 min50 min Note: References for instruments included at the end

6. Demographics  N = 87 (female = 44; male = 43)  Live alone (yes = 20.7%; no = 79.3%)  Employed (yes = 43.7%; no = 56.3%)  Education  6 th Grade or less = 1.1%  Partial High School = 4.6%  High School Diploma/GED = 21.8%  Partial College = 34.5%  Completed College = 21.8%  Graduate/professional training = 12.6%  Other = 2.3%  Organized Religion (yes = 62.4%; no = 37.6%)  Tribal traditional spiritual practices: (yes = 67.8%; no = 32.2%)

7. Grief History: Number of Deaths per Participant in Past 5 Years

8. Preliminary Results MEASUREGroups 5 & 6 Historical Loss Scale (Developed for Native Americans) Participants thought more about Historical Loss [T1 (M = 44.67) – T2 (M = 47.33) – T3 (M = 41.0) – (T4 (M = 34.78); p =.033, eta =.328, n = 9] Historical Loss Associated Symptom Scale (Developed for Native Americans) NSF Anxiety/Depression (T1 – T3, p =.06, eta =.273, n = 9) Anger/Avoidance (NSF) Brief COPE InventoryCoping/Planning (NSF) Acceptance (NSF) Humor (NSF) Religion (NSF) Support (NSF) Distraction/Venting (NSF) Denial/Self-Blame (NSF) Substance Use [T1 – T3, p <.038 and T1 – T4, p <.05] Behavioral Disengagement (NSF) Brief Resilience ScaleNSF Overall, the participants’ scores demonstrated resilience (M = 20.143 – 19.143, n = 7) MSDN T15.302.4910 T24.801.9310 T33.10*1.7310 T43.40*1.8419

9. Preliminary Results (continued) Interpersonal Support Evaluation List Appraisal [T1 (M = 22.3) – T2 (M = 18.2), p < 0.05; n = 10] Tangible (NSF) Self-Esteem Support (NSF) Belonging Support [T1 – T2, p =.135, eta =.256] The Intervention had an impact on participants’ feelings of support and belonging while in the group Kessler-6 ScalePsychological Distress decreased significantly when in group, then increased (but not significantly) [T1 (M = 19.8) – T2 (M = 22.5), n = 10, p <.05, eta =.403] Positive and Negative Affect Schedule Positive Affect stayed essentially the same (n = 8) Negative Affect DECREASED initially and then returned to baseline at 3 month follow-up (n = 9) NSF Brief Resilience ScaleNSF Overall, the participants’ scores demonstrated resilience (M = 20.143 – 19.143, n = 7)

10. Preliminary Assessment of the Inventory of Traumatic Grief Question: Can the ITG be used with Native American populations? Inventory of Traumatic Grief (ITG) Developed for Euro/American populations Two domains: Separation & traumatic distress Focus: Grief related to loss of a significant other ITG culturally vetted: Relevance and offensiveness Slight modifications made Noted: ITG focuses on one death; Native Americans often experience frequent, multiple, and layered deaths Convergent validity (ITG & HLASS) Conclusion: Statistical significance suggests measurement of the same construct, grief, but low r values may represent differing domains in the larger grief construct.

11. Inventory of Traumatic Grief N = 87; M = 57.94; SD = 25.64; Range = 0 - 150 Cut Score is 90 10 (of the 87 participants, 11%) scored above 90

12. Individual Family Tribal Community Traditional Homelands Emerging Model: Grief and Resilience GRIEF is experienced on multiple levels Grief begins a process that is met with multiple levels of RESILIENCE GRIEF RESILIENCE

13. Presentation References Brendtro, L.K., M. Brokenleg, and S. Van Bockern, Reclaiming youth at risk: Our hope for the future. 1990, Bloomington, IN: Solution Tree. DeRoche, M.L. and M. Malatare, Historical trauma and the grief life cycle, in Alberta Delegated First Nations Agencies: Best Practices Symposium "Nii stow a tsi maan: Raising Our Children". 2010: Edmonton, Alberta, Canada. References for Instruments Historical Loss Scale & Historical Loss Associated Symptoms Scale Walls, M.L. and L.B. Whitbeck, Distress among Indigenous North Americans: Generalized and culturally relevant stressors. Society and Mental Health, 2011. 1(2): p. 124-136. Walls, M.L. and L.B. Whitbeck, The intergenerational effects of relocation policies on Indigenous families. Journal of Family Issues, 2012. 33(9): p. 1272-1293. Whitbeck, L.B., et al., Conceptualizing and measuring historical trauma among American Indian people. American Journal of Community Psychology, 2004. 33(3/4): p. 119-130. Whitbeck, L.B., et al., Depressed affect and historical loss among North American Indigenous adolescents. American Indian and Alaska Native Mental Health Research, 2009. 16(3): p. 16-41.

14. Inventory of Traumatic Grief Boelen, P.A., et al., Reliability and validity of the Dutch version of the Inventory of Traumatic Grief (ITG). Death Studies, 2003. 27: p. 227-247. Jacobs, S.C., C. Mazure, and H. Prigerson, Diagnostic criteria for traumatic grief. Death Studies, 2000. 24: p. 185-199. Jacobs, S.C. and H.G. Prigerson, Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatments. Death Studies, 2000. 24: p. 479-495. Prigerson, H.G., et al., Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 1997. 154(5): p. 616-623. Prigerson, H.G., et al., Influence of Traumatic Grief on suicidal ideation among young adults. American Journal of Psychiatry, 1999. 156(12): p. 1994-1995. Prigerson, H.G., et al., Prolonged grief disorder: Psychometric Validation of criteria proposed for DSM-V and ICD-11. PLoS Med 2009. 6(8). Prigerson, H.G. and S.C. Jacobs, Traumatic grief as a distinct disorder: A rationale, consensus criteria and a preliminary empirical test, in Handbook of bereavement research: Consequences, coping, and care, M.S. Stroebe, et al., Editors. 2001, American Psychological Association Press: Washington, DC. p. 613-645. Prigerson, H.G., et al., Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 1995. 59: p. 65-79. Prigerson, H.G., et al., Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatriy, 1999. 174: p. 67-73. Prigerson, H.G., et al., Traumatic Grief: A case of loss-induced trauma. American Journal of Psychiatry, 1997. 154(7): p. 1003-1009.

15. Inventory of Traumatic Grief (cont.) Shear, K., et al., Traumatic grief treatment: A pilot study. American Journal of Psychiatry, 2001. 158(9): p. 1506-1508. Shear, K., et al., Treatment of complicated grief. Journal of the American Medical Association, 2005. 293(21): p. 2601-2608. Shear, K., et al., Screening for complicated grief among project liberty service recipients 18 months after September 11, 2001. Psychiatric Services, 2006. 57(9): p. 1291-1297. Shear, K. and K. Smith-Caroff, Traumatic loss and the syndrome of complicated grief. PTSD Research Quarterly, 2002. 13(1): p. 1-7. Brief COPE Carver, C. S. (1997). You want to measure coping but your protocol's too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4(1), 92-100. Hobfoll, S., Jackson, A., & Hobfoll, I. (2002). The impact of communal-mastery versus self-mastery on emotional outcomes during stressful conditions: A prospective study of Native American women. American Journal of Community Psychology, 30(6), 853- 871. Hobfoll, S., & Schroder, K. (2001). Distinguishing between passive and active prosocial coping: Bridging inner-city women's mental health and aids risk behavior. Journal of Social and Personal Relationships, 18(2), 201-217.

16. Brief Resilience Scale Long, C., & Nelson, K. (1999). Honoring diversity: The reliability, validity, and utility of a scale to measure Native American resilience. Journal of Human Behavior in the Social Environment, 2(1-2), 91-107. Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Jennifer, B. (2008). The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15, 194-2000. Windle, G., Bennett, K. M., & Noyes, J. (2011). A methodological review of resilience measurement scales. Health and Quality of Life Outcomes, 9(8). Interpersonal Support Evaluation List Cohen, S., & Hoberman, H. M. (1983). Positive events and social supports as buffers of life change stress. Journal of Applied Social Psychology, 13(2), 99-125. Cohen, S., Mermelstein, R., Kamarck, T., & Hoberman, H. M. (1985). Measuring the functional components of social support. In I. G. Sarason & B. R. Sarason (Eds.), Social support: Theory, research and applications (pp. 73-94): NATO ASI Series: Series D: Behavioral and Social Sciences, No 24.

17. Kessler-6 Furukawa, T. A., Kessler, T., Andrews, G., & Andrews, S. (2003). The performance of the K6 and K10 screening scales for psychological distress in the Australian national survey of mental health and well-being. Psychological Medicine, 33, 357-362. Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S.-L. T.,... Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine(32), 959-976. Kessler, R. C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., Howes, M.J., Normand, S.T., Manderscheid, R.W., Walters, E.E., Azslavsky, A.M. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60, 184-189. Kessler, R. C., Green, J.G., Gruber, M.J., Sampson, N.A., Bromet, E., Cuitan, M., Furukawa, T.A., Gureje, O., Hinkov, H., Hu, C., Lara, C., Lee, S., Mneimneh, Z., Myer, L., Oakley- Brown, M., Posada-Villa, J., Sagar, R., Viana, M.C., Zaslavsky, A.M. (2010). Screening for serious mental illness in the general population with the K6 screening scale: Results from the WHO World Mental Health (WMH) survey initiative. International Journal of Methods in Psychiatric Research, 19(Si[[;e,emt 1), 4-22. Manson, S. M., Jiang, L., Zhang, L., Beals, J., Acton, K.J., Roubideaux, Y., SDPI Healthy Heart Demonstration Project,. (2011). Special diabetes program for Indians: Retention in cardiovascular risk reduction. The Gerontologist, 51(S1), S21-S32. Mitchell, C. M., Beals, J. (2011). The utility of the Kessler Screening Scale for Psychological Distress (K6) in two American Indian communities. Psychological Assessment, 23(3), 752- 761.

18. Kessler-6 (cont.) Parker, T., Maviglia, M.A., Lewis, P.T., Gossage, J.P., May, P.A. (2010). Psychological distress among Plains Indian mothers with children referred to screening for Retal Alcohol Spectrum Disorders. Substance Abuse Treatment, Prevention, and Policy, 5(22), 22-30. Wittchen, H. (2010). Editorial: Screening for serious mental illness: methodological studies of the K6 screening scale. International Journal of Methods in Psychiatric Research, 16(Supplement 1), 1-3. Positive and Negative Affect Schedule Crawford, J. R., & Henry, J. D. (2004). The Positive and Negative Affect Schedule (PANAS): Construct validity, measurement properties and normative data in a large non-clinical sample. British Journal of Clinical Psychology, 43, 245-265. Thompson, E. R. (2007). Development and validation of an internationally reliable short- form of the Positive and Negative Affect Schedule (PANAS). Journal of Cross-Cultural Psychology, 38(2), 227-242. Watson, D., Clark, L. A., & Tellegen, A.,. (1988). Development and validation of brief measures of positive and negative affect: The PANAS Scales. Journal of Personality and Social Psychology, 54 (6), 1063-1070.

19. Acknowledgements Mary Louise DeRoche, MSH, LAC Melveena Malatare, MA, LAC Annie Belcourt, PhD InPsych Research Team Ann Douglas, MA; Ciara Hansen, MA; Desiree Pierre-Fox, MA; Ennis Vaile, MA; Georgie Ferguson, MA; Jennie Fretts, MA; Maegan Rides at the Door, MEd; Matthew Croxton, MA; Raquel Arouca, PhD; Vernon Grant, MS; William Shunkamolah, PhD Maria Yellow Horse Brave Heart, PhD Ray Daw, MA This project was supported by a grant from the National Institute of General Medical Sciences (8 P20 GM103474-11) from the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health

20. Lemlmtš Thank you! QUESTIONS? gyda.swaney@umontana.edu ke.wu@umontana.edu pholkup@montana.edu emilymatt@bresnan.net