Complex Developmental Trauma and Historical Trauma Jeanne Bereiter

Complex Developmental Trauma and Historical Trauma Jeanne Bereiter, MD Caroline Bonham, MD Maria Yellow Horse Brave Heart, Ph. D Division of Community Behavioral Health Department of Psychiatry and Behavioral Sciences University of New Mexico Health Sciences Center Albuquerque, NM

Setting the Stage From: http: //www. slate. com/blogs/the_vault/2014/06/17/interactive_map_loss_of_indian_land. html

Learning Objectives • Evaluate the interactions between historical trauma, attachment, and complex developmental trauma in Indian Country • Summarize historical and cultural considerations in healthcare and behavioral health treatment with American Indians and Alaska Natives • Describe the symptoms of attachment disorder, PTSD, and complex developmental trauma and determine appropriate treatment of these disorders • Integrate knowledge of historical trauma and complex trauma into care of patients with medical, behavioral, and substance use disorders

Ground Rules based upon the Woope Sakowin (7 Laws of the Lakota) • Wacante Ognake - Generosity – To share time with others, to share opinions, thoughts and feelings in a good way – To remain silent at times to allow others to share – To share, help, give • Wowaunsila – Compassion, Pity – Compassion for other participants © Maria Yellow Horse Brave Heart, Ph. D

Ground Rules (Con’t. ) • Wowayuonihan – Respect, Honor – To have respect and honor for others – Each opinion is valued • Wowacin Tanka - To Have a Great Mind – To be patient and silent, and to observe – No need to repeat what has already been said – Patience, tolerance © Maria Yellow Horse Brave Heart, Ph. D

Ground Rules (Con’t. ) • Wowahwala – Humility, State of Silence, To be humble – To put the good of the group first – No one is above another • Woohitike – Courage, Bravery, Principal, Discipline – To be honest © Maria Yellow Horse Brave Heart, Ph. D

Ground Rules (Con’t. ) • Woksape – Wisdom, Understanding – Wisdom which is sought through respectful listening and observing – Use wisdom in the group process – Self-discipline; focus on the task at hand © Maria Yellow Horse Brave Heart, Ph. D

Definitions • Trauma results from event/circumstances experienced as physically or emotionally harmful or threatening with lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being* • Historical trauma - Cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan • Historical trauma response (HTR) is a constellation of features in reaction to massive group trauma, includes historical unresolved grief (similar to other massively traumatized groups (Brave Heart, 1998, 1999, 2000) * (Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 134801) © Maria Yellow Horse Brave Heart, Ph. D

Complex Trauma/ Complex Developmental Trauma • Complex trauma - prolonged, repeated trauma in which the person was “in a state of captivity” physically or emotionally (Herman, 1997). • Complex developmental trauma – childhood exposure to multiple traumatic events and the wide-ranging, long-term impact of this exposure. Because the onset of these traumas is early in life, they have profound effect on development and attachment.

Complex Trauma and Historical Trauma • Early reservation days and POW designation for some tribal groups, massacres, colonization, forced separation of children from families and tribe, may be emotionally experienced as a legacy of living in a state of captivity. • Treatment involves need for person to regain sense of control and power, and work in interpersonal relationships – many AIAN face repeated disruption in sense of agency and experiences collectively of powerlessness related to past and ongoing oppression, e. g. DAPL which has been triggering for AIAN

Example of Traditional Cultural Perspectives on Collective Trauma and Grief It is our way to mourn for one year when one of our relations enters the Spirit World. . . tradition is not to be happy, not to sing and dance and enjoy life’s beauty during mourning time…. to suffer with the remembering of our lost one…. And for one hundred years we as a people have mourned our great leader… 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. * *From a booklet for the Sitting Bull and Bigfoot Memorial Ride; Traditional Hunkpapa Lakota Elders Council (Blackcloud, 1990) © Maria Yellow Horse Brave Heart, Ph. D

Boarding School Era: Further Trauma for AIAN In contrast to language in Treaty of Ft. Laramie asking for regular day schools in the community • 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). © Maria Yellow Horse Brave Heart, Ph. D

Impact of HT & Early Boarding School Policy on Native Parents • Disempowerment of our sacred roles and sacredness of women and children • Devaluation of traditional Native parenting and removal of our basic rights to raise our children in our own ways • Negative impact upon our self-esteem as parents and as Native Peoples • Increase in domestic violence/child abuse which were foreign to Native cultures © Maria Yellow Horse Brave Heart, Ph. D

Confronting the Past: Historical Trauma, Genocide and Survival • 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 started under the War Department; BIA Education Division called “Civilization Division” • Congressional policy of forced separation of children from family and tribe; militaristic • Massacres (e. g. 1890 Wounded Knee Massacre of Lakota), mass graves, forced sterilization of Native women in the 1950 s © Maria Yellow Horse Brave Heart, Ph. D

Cumulative Massive Group Trauma • Origins of trauma are in genocide; negative boarding school experiences, generational adversity compounded trauma • Trauma is transferred across generations through impairment of traditional parenting skills, identification, and other complex processes; epigenetics research relevant “inheriting grief and trauma responses” • Children of genocide survivors, children of boarding school survivors may pass on the trauma to their descendants – behavioral but possible alteration of DNA; traumatic exposure altering brain chemistry

Confronting the Past: American Indian Genocide and Survival From Wiping the Tears of Seven Generations: The Bigfoot Memorial Ride: • General Sherman: First clear off the buffalo, then clear off the Indian. We must act with vindictive earnest against the Sioux even to their total extermination – men, women, and children. • Patrick Cudmore, Oglala Lakota College – Never before in the whole of human history has the near extermination of a race been so total and complete as it was in the United States. Historian Helen Tanner – U. S. never intended the long term survival of the Lakota but treaties became a cheaper alternative to war. © Maria Yellow Horse Brave Heart, Ph. D

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 © Maria Yellow Horse Brave Heart, Ph. D

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 • Similarities with the Child of Survivors Complex (Holocaust), Japanese American internment camp survivors and descendants but tribal cultural differences • Loyalty to ancestral suffering & the deceased • Internalization of ancestral suffering • Vitality in own life seen as a betrayal to ancestors who suffered so much © Maria Yellow Horse Brave Heart, Ph. D

HT, Depression, PTSD, Prolonged Grief • High rates of PTSD associated with trauma exposure, frequent deaths, military trauma (Manson, et al. , 2005; Brave Heart, Lewis-Fernandez, Beals, et al. , 2016). • CG/PG: sadness, separation distress, strong yearnings, longing for & preoccupation with thoughts of deceased, 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). • May co-occur with PTSD (20 -50%). • 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 © Maria Yellow Horse Brave Heart, Ph. D

Types of Trauma that can lead to trauma related diagnosis • Single event – E. g. being in a car crash, natural disaster, sexual assault, medical procedure • Multiple events, over time – E. g. incest, war, racism, micro-aggressions, multiple medical procedures • Complex developmental trauma • Vicarious or secondary trauma • Multigenerational including historical trauma

PTSD Complex Developmental Trauma Acute Stress Disorder Trauma Related Diagnoses Disinhibited Social Engagement Disorder Complex Trauma Reactive Attachment Disorder

Caveats • What is traumatic to 1 person may not be to another • Trauma affects a person’s neurobiology in ways that are long lasting or permanent • Trauma can lead to – adverse health outcomes – Trauma related diagnoses • Not everyone who has experienced trauma develops PTSD or trauma related diagnosis • There are effective treatments for trauma related symptoms

Prevalence of PTSD in USA • • • Lifetime risk for development of PTSD by age 75 is 8. 7% Lower rates among children Lower rates among elderly Higher rates among veterans, occupational exposure Certain ethnicities have higher rates compared to non Hispanic white: AI/AN, Latinos, African Americans • Higher rates of PTSD among AI/AN is related to higher degree of exposure to trauma • Survivors of rape, military combat and captivity, ethnically or politically motivated internment and genocide especially high rates of PTSD – More than 1/3 to ½ of those exposed develop PTSD

Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder • Absence of adequate caregiving (social neglect) during childhood is a diagnostic criterion • Neglect is emotional, interferes with attachment • Neglect may also be physical • Neglect can be due to – Repeated changes in primary caregiver e. g. , foster care – Rearing in an institutional setting e. g. , orphanage – Emotional unavailability of primary caregiver e. g. , maternal depression or substance use

Features of Disinhibited Social Engagement Disorder • Overly familiar verbal or physical behavior • Diminished checking back with adult caregiver after venturing away • Willingness to go off with unfamiliar adult with little hesitation • Can be seen if child reared in settings with high turnover or chaos • Places the child at risk of further abuse Creating Cultures of Trauma Informed Care (CCTIC)

Reactive Attachment Disorder • Rarely seeks or responds to comfort when distressed • Minimal social responsiveness to others • Limited positive affect • Unexplained irritability, sadness or tearfulness Creating Cultures of Trauma Informed Care (CCTIC)

Complex Trauma • Not a DSM 5 diagnosis but planned for inclusion in ICD 11 • DSM IV field trial showed that 92% of people with complex PTSD/Complex Trauma also met diagnostic criteria for PTSD • Found in people who have experienced multiple, chronic or multiple traumas • Presents with symptoms that do not fit easily with DSM categories: dissociation, anger, depression, change in self concept, change in response to stressful events, dysregulation of multiple symptom domains including body, sensory and motor

Treatment of Complex Developmental Trauma and Complex Trauma • Helping person to regain sense of control and power • Development and enhancement of interpersonal relationships • Focus on developing connections between somatic and emotional symptoms • Focus on security, stability and emotional sensitivity • Medications can be used to reduce associated intense symptoms such as insomnia, depression, explosive anger or impulsivity but do not address the root of the problems

Complex Developmental Trauma • Onset of traumatic experiences early in life that occur in context of a child’s relationship to a primary caregiver • Interference with child’s ability to form a secure attachment bond • Frequently presents with diagnoses such as ADHD, childhood bipolar disorder or psychosis • No current construct for diagnosis in the DSM 5 and therefore concern that children with these symptoms are at risk for over medication • Rates of antipsychotic use ranging between 30 -67% among children in foster care settings Creating Cultures of Trauma Informed Care (CCTIC)

Creating Cultures of Trauma Informed Care (CCTIC)

PTSD in AI/AN Population • AI/AN communities in general have higher risk of experiencing trauma than any other ethnic group • Twice as likely as general population to develop PTSD • Higher levels of PTSD reflect higher exposure to trauma • Related problems: body pain, lung disorders, general health problems, substance abuse, pathological gambling • Most frequently implicated trauma is military combat • 2 nd most common was interpersonal violence • Protective factors: – Traditional non Christian religious practices • Little research on effective treatments Bassett et. al. , 2014

Ongoing Cumulative, Multiple Losses and Trauma Exposure • Intergenerational parental trauma traced back to legacy of negative boarding school experiences • Constant trauma exposure related to deaths from alcohol -related incidents, suicides, heart disease, diabetes, cancer, etc. • Surviving family members include individuals who are descendants of massive tribal trauma (e. g. massacres, abusive and traumatic boarding school placement) • Cumulative trauma exposure – current and lifespan trauma superimposed on collective massive • American Indians have the highest military enlistment rate than any other racial or ethnic group – extends traumatic exposure © Maria Yellow Horse Brave Heart, Ph. D

Culturally Sensitive Diagnosis: the DSM Cultural Formulation Cultural Identity • Ethnic or cultural reference group(s) • Degree of involvement w/culture of origin & host culture • Language abilities, use, & preference Cultural Explanations of Illness • Meaning & perceived severity of symptoms in relation to reference group/s norms • Perceived causes & explanatory models that the pt. & reference group(s) use to explain the illness • Preferences for sources of care © Maria Yellow Horse Brave Heart, Ph. D

Culturally Sensitive Diagnosis: the DSM Cultural Formulation Cultural factors related to psychosocial environment & levels of functioning • Culturally relevant interpretations of social stressors, available supports, levels of functioning & disability • Stresses in the local social environment • Role of religion & kin networks in providing emotional, instrumental, & informational support © Maria Yellow Horse Brave Heart, Ph. D

Culturally Sensitive Diagnosis: the DSM Cultural Formulation Cultural elements of the relationship between the individual and the clinician • Individual differences in culture & social status between the individual & clinician • Problems these differences may cause Overall cultural assessment for diagnosis and care • Discussion of how cultural considerations specifically influence comprehensive diagnosis and care Examples for Native clients: skin color issues, risk for trauma exposure, traditional mourning practices, racism, unemployment rates, housing availability © Maria Yellow Horse Brave Heart, Ph. D

Cultural Formulation specific to AIAN • Indirect styles of communication, values of noninterference and non-intrusiveness, & polite reserve may delay help-seeking and true presenting problem • Variation in eye contact; cultural differences in personal space & cross-gender interaction • Listening for the meaning in the metaphor • Client use of narratives, stories; talking in the displacement • Beginning phase may be longer © Maria Yellow Horse Brave Heart, Ph. D

Culturally & Historically Responsive Assessment • Explore generational boarding school history, tribal traumatic events, and investigate how these were/are processed in the family • Explore degree of involvement in traditional Indigenous culture; complexity of cultural responsiveness • Use adaptation of the DSM IV & 5 Cultural Formulation (Lewis-Fernandez & Diaz, 2002), expanded to include exploration of boarding school trauma, tribal relocations, migration, trauma in tribal community of origin, language © Maria Yellow Horse Brave Heart, Ph. D

Use of Self, Transference and Countertransference • The theory you embrace informs your assessment and intervention • Psychoanalysts and psychoanalytic or psychodynamic therapists (including clinical social workers, psychologists, psychiatrists) work with concepts like transference, countertransference, bolstering ego strengths, impulse control and judgement, delayed gratification, superego and ego ideals, sense of self, and object relationships • Some research indicates the power of therapeutic relationships and success with varying models – not one size fits all. • Countertransference reactions can be induced – learning to work with observing your own reactions in a session can be very helpful in therapy.

Trauma Informed Use of Self, Transference and Countertransference • Trauma narratives of patients will be triggering particularly if therapist has own trauma history. • Developing comfort with one’s own reactions and working on healing from one’s own trauma is essential. • Awareness of trauma is helpful rather than harmful (avoidance is worse as one can “act out” by not listening to the patient, shutting down emotionally, becoming judgmental, and interfering with the patient’s healing) • Trauma informed care includes addressing providers own needs and healing. Review information on Secondary, Vicarious Trauma, Compassion Fatigue, and Burnout from last session and kickoff slides. As you watch/listen to the DVD clips think of being in a session with person talking and attend to how you are experiencing this; think about HT, HTR, and the Cultural Formulation.

Celebration of Survival

VETERANS VIDEO Creating Cultures of Trauma Informed Care (CCTIC)

Discussion

STRESS, NEUROBIOLOGY, AND EPIGENETICS

Epigenetics, Transgenerational Effects, and PTSD • Transgenerational, higher stress vulnerability (doesn’t mean poor mental health necessarily but greater risk for traumatic responses to stress and more likely to have PTSD-like symptoms) • Stressful environmental conditions can leave a genetic imprint, changes in neurobiology • Testimonies of “inherited” grief in qualitative research • • Yehuda & Bierer, (2009) J of Traumatic Stress, 22 (5) • Yehuda, et al. , (2005) J of Clinical Endocrinology & Metabolism, 90 (7) Walters et al. , (2011) Du Bois Review: Social Science Research on Race, 8(1) © Maria Yellow Horse Brave Heart, Ph. D

Acute Stress • Our bodies are designed to deal with acute stress • Fight/flight/freeze reaction is initiated • This stress response system increases our ability to survive danger • Once stress is over systems return to normal (homeostasis) via negative feedback loops

Defense Cascade: Fight, Flight, or Freeze Stressor: physical, emotional Arousal: need to respond fight flight freeze

Freeze Response • Attentive immobility • Usually lasts for only a few seconds • Allows person to assess the danger and decide whether to fight or flee • Often begins with freeze (assess the situation, hide from predator, then respond) • Includes opioid-mediated analgesia, lower HR • Increased occurrence in people with trauma histories when person is exposed to a cue associated with a previously negative event • Can lead to immobility, dissociation

Dissociation • Our mind’s “safety valve” • When overstimulated, we shut down, or dissociate thoughts from feelings/body from thoughts • Can manifest as: – – – Fainting Emotional numbing Amnesia Conversion into physical symptoms Fragmentation of sense of self • Can lead to dissociative disorders (DSM 5)

Chronic Stress • Our bodies are not designed to deal with persistent stress • Same systems are activated as in acute stress, but are activated over and over – This has adverse effects: • Initial high levels of cortisol then blunted corticosteroid release • Brain changes (high levels of cortisol are toxic) – Impairs neural plasticity, damages the hippocampus which impairs memory • Epigenetic changes

http: //www. 2 ndacthealth. com/2015/07/cortisol-part-1 relationship-to-stress/

Normal Brain Development • The brain isn’t structurally complete at birth • It is designed to develop based upon cues from the environment – Brain growth requires • Interaction with loving, predictable people • A healthy physical environment • Children haven’t yet developed fully the ability to regulate arousal • They require help from adults https: //www. aap. org/en-us/Documents/ttb_aces_consequences. pdf

ACES VIDEO Creating Cultures of Trauma Informed Care (CCTIC)

PET scan of healthy childhood brain versus child with history of abuse Creating Cultures of Trauma Informed Care (CCTIC)

How Trauma Interferes With Normal Brain Development • Trauma interferes with normal biological maturation – Adversely effects neurodevelopment • Structurally • Neuroendocrine systems • Immune system • Epigenetics • Traumatized parents often have difficulty helping their children’s brain development https: //www. aap. org/en-us/Documents/ttb_aces_consequences. pdf

Structural Brain Changes with Early Life Stress • The earlier the stress/abuse and the longer it lasts, the more likely a person will have: – Decreased cerebral volume – Decreased corpus callosum size – Decreased hippocampal volume (adults) – Abnormalities in the amygdala

Corticolimbic System https: //au. pinterest. com/explore/anterior-cingulate-cortex/

Clinical Effects Of Stress Induced Neurobiological Changes • Decreased ability to put experience into words • Decreased ability to think through a situation • Memory problems • Instead, people experience strong emotions, sounds, smells, impressions (often nonverbal)

Anhedonia (inability to experience pleasure) and Reward Seeking Behavior • Early life stress can lead to anhedonia and compensatory increased reward seeking behavior – substance use, promiscuity • May be related to abnormalities in dopamine system – decreased DA response to reward stimulating cues • Increased smoking may be self medication for anhedonia – nicotine stimulates dopamine

Addicted to Stress? • Some evidence that chronic exposure to stress may cause chronically elevated endogenous opiates • When stress is relieved, people feel worse rather than better (sx of opiate withdrawal? ) • Results in paradoxical behavior—people seek out stressful or re-traumatizing situations to increase their endorphins

What is Epigenetics? • Functional changes in genes without altering their DNA sequence • Is the way gene expression is influenced by experience/environment • Controls which genes are expressed, & how much/when • Usually transient/ reversible • Some of these changes can be stabilized and inherited (animal models) • Can be transmitted to offspring (from one generation to another)

Epigenetics and Stress/Trauma • Stress and trauma trigger epigenetic changes • Studies show that childhood abuse causes increased or decreased methylation in certain genes (e. g. , involved in immune function, glucocorticoid receptors, stress response, neurotransmitter activity) • PTSD is associated with suppressed cortisol levels (due to hypersensitivity of the glucocorticoid receptor & enhanced negative feedback) (HPA axis abnormalities) http: //learn. genetics. utah. edu/content/epigenetics/inheritance/; Voisey et. al. , 2014; ; Zannas et. al. , 2015)

Creating Cultures of Trauma Informed Care (CCTIC)

Attachment

Attachment • Social contact is as necessary to our survival as food and water – Failure to thrive in orphanages, can lead to death • Babies are dependent upon their caregivers • They develop attachment to their primary caregivers— other adults won’t do (Stranger anxiety at 6 -9 months) • They develop attachment to caregivers even if the caregiving is abusive or neglectful • With loss of caregiver child protests, then falls into despair • Eventually, child loses interest in attachment (see RAD) • Lack of attachment figures is a type of trauma

Harry Harlow and Monkey Experiments https: //sites. google. com/site/hookappsychology 2 a/key-experiments-by-maticyn-milia/harry-harlow-s-monkey-experiment

Attachment-continued • Attachment between child and caregiver makes child feel safe, secure, protected • Primary attachment figures help regulate the infant’s brain • Infant learns through attachment figure(s) how to self soothe, recognize emotions • Without good attachment, infant is at higher risk of psychological problems, abnormal brain development • Attachment protects against social and emotional maladjustment

Mirror Neurons • Network of neurons in the brain • Our neurons fire when performing and behavior and when observing the same behavior in others • We understand the other’s intention • This allows us to imitate behavior, and understand what others feel http: //www. thenervousbreakdown. com/wpcontent/uploads/2014/06/mirror-neuron 1. jpg

Theory of Mind • The ability to understand that we have mental states (beliefs, intents, desires) and that others have mental states different from our own • Thought to begin around age 4

Mary Ainsworth and The Strange Situation • Mary Ainsworth was a developmental psychologist who helped to develop attachment theory • “Strange Situation” is a laboratory procedure to study attachment in children age 10 months-5 years • Evaluates – how much infant/child explores – Reaction to caregiver’s absences/return

Types of Attachment-Secure • Secure 55%-60% general population – Caregiver consistently responds to distress in sensitive, responsive ways – Infant goes to caregiver for soothing, also able to play/explore – Infant sees caregiver as caring and loving, and self as worthy – As child grows, they are more able to get along with peers, handle conflict

Types of Attachment. Insecure/Avoidant • Insecure/Avoidant 23% – Caregiver is rejecting of infant’s needs/non-responsive – Infant doesn’t go to caregiver for soothing – Infant learns to deal with distress by itself, be independent

Types of Attachment-continued • Insecure/ Resistant 8% – Caregiver responds in inconsistent manner, or needs infant to respond to her own needs – Infant has trouble being soothed by caregiver, can be angry/rejecting • Disorganized – Caregiver responds in frightening/atypical ways – Infant behaves in contradictory ways e. g. fear of caregiver, freezing – Nearly 80% of maltreated children have this attachment style

Repairing Ruptures • There always ruptures in attachment • The important thing is to repair them • Repair acknowledges the rupture, and attempts to reconnect

Winnicott: good enough Creating Cultures of Trauma Informed Care (CCTIC)

Failure to Thrive http: //covenantbuilders. blogspot. com/2012/03/unbeloved. html

Sensitive Periods for Attachment & Normal Infant Development • Language <15 months • Attachment <24 months

Attachment Can be Improved • Via enriched environment • Attentive caregiver • E. g Bucharest Early Intervention Project – Prior to the study 65% of institutionalized children had disorganized attachment, 13% had no attachment – At 42 months 49% of children in foster care had secure attachments versus 18% in institutionalized group versus 65% living with their parents – Decrease in RAD and improvement in cognitive functioning found as well Nelson et al; 2009

Adult Attachment is Important • Attachment status of the parent can be evaluated – Adult attachment interview • If parent is securely attached, infant is likely to be securely attached • If parent is insecurely attached, infant is likely to be insecurely attached

Attachment: AIAN Cultural and Historical Perspectives and Risk Factors for Traumatic Grief and Depression • Attachment figures include extended family kinship networks • Cultural differences in quality and intensity of attachment – distant relatives by European American standards are close kin in AIAN cultures – extends both risks for grief and conversely social support • Example of tribes who cut their hair in mourning – symbolic of a loss of part of oneself; continued relationships with ancestor spirits which may differ from European American grief reactions and mourning

Intergenerational Transmission • Children of trauma survivors are at increased risk for mental and physical illnesses • Parental PTSD leads to alterations in the HPA axis function of children • This is mediated by developmental programming of glucocorticoid signaling via epigenetic modifications • Stress during mother’s pregnancy can affect epigenetics in the fetus • Some epigenetic changes prior to pregnancy (and paternal epigenetic changes) can be passed on to children Yehuda 2014

Cycle of Intergenerational Trauma • Approximately 1/3 of adults who experienced childhood abuse will go on to neglect or abuse their children. (Kaufman and Ziegler, 1987) • Families with patterns of physical abuse, aggression and violence continue to be at high risk for these behaviors for at least three generations. (Conger et al, 2003; Ehrensaft et al, 2003) • Similar patterns with substance use (Fuller et al. , 2003); and sexual abuse (Lev-Wiesel, 2006)

Children born to mothers with substance abuse conditions are more likely to have: – Increased irritability – Increased medical frailty – Worse sleep – More feeding difficulties Increased maternal stress Decreased maternal sleep Increased risk for child abuse

I really want classes that show to cope with your own emotions. When I found myself getting mad at my son I can almost see my mom and hear my mom and what she use to do to me and my brother. I try to block it out but it is so hard to block it out because it was embedded in my brain and mind for so long and still to this day.

• [I want to learn] how to parent with healthy fear because I think that anyone who has had one of those traumatic events is going to have fear of it happening to their child and there has to be a line between protecting your child and overprotecting… learning how to let them live but still protect them and teach them.

• [I want to learn] how to parent with healthy fear because I think that anyone who has had one of those traumatic events is going to have fear of it happening to their child and there has to be a line between protecting your child and overprotecting… learning how to let them live but still protect them and teach them.

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) © Maria Yellow Horse Brave Heart, Ph. D

American Indian Genocide and Survival From Wiping the Tears of Seven Generations: The Bigfoot Memorial Ride: • General Sherman: First clear off the buffalo, then clear off the Indian. We must act with vindictive earnest against the Sioux even to their total extermination – men, women, and children. • Patrick Cudmore, Oglala Lakota College – Never before in the whole of human history has the near extermination of a race been so total and complete as it was in the United States. Historian Helen Tanner – U. S. never intended the long term survival of the Lakota but treaties became a cheaper alternative to war. © Maria Yellow Horse Brave Heart, Ph. D

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). © Maria Yellow Horse Brave Heart, Ph. D

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. © Maria Yellow Horse Brave Heart, Ph. D

Attachment: AIAN Cultural and Historical Perspectives and Risk Factors for Traumatic Grief and Depression • Disruption in attachment related to forced boarding school placement, disruption of child’s sense of safety, security, feeling protected (racism also impacts this – limits on how AIAN parents can protect their children) • Capacity to self-soothe disrupted by early boarding school placements, racial trauma • AIAN communities need to examine attachment, mourning, and revitalize culturally congruent ways for grieving and mourning that are grounded in traditions as well as addressing the current reality of the collective historical and ongoing trauma exposure.

Trauma in Indian Country (Bigfoot, 2008) Oppression Accidental Death Violence Incarcerati on Cumulati ve (Collectiv e) Trauma Substance Use Historical Events Suicide Child Abuse & Neglect Domestic Violence Poverty

Perceived Discrimination and Microagressions • Perceived discrimination - relationship with increased depression (see Whitbeck) • Microagressions (term coined by Chester Pierce, MD; further development by D. Wing Sue, Ph. D) can include instances of being racially profiled, experiences of discrimination, being stereotyped, being intentionally or unintentionally excluded, hearing racist comments, etc. • Associated with historical trauma response, PTSD symptoms, and depression (preliminary research of Dr. Karina Walters (Choctaw) U of WA © Maria Yellow Horse Brave Heart, Ph. D

Discrimination, Microagressions, and White Privilege • Concept of White Privilege (Peggy Mc. Intosh) • The dominant cultural environment is primarily based upon Anglo Saxon Protestant culture, the predominant culture in the United States • Unconscious, often unintentional bias, discrimination, and conscious bias • Dominant cultural groups have privilege of their worldview being predominant • Challenging for Natives to navigate the world due to differences in culture, in ways of processing thoughts and communicating, different values and world views, etc. © Maria Yellow Horse Brave Heart, Ph. D

Perceived Discrimination • Perceived discrimination has been studied re: impact on both mental and physical health through psychological and physiological stress responses and health behaviors • Perceived discrimination produces significantly heightened stress responses and is related to unhealthy behaviors

Culturally & Historically Responsive Assessment • Explore instances of perceived discrimination and microaggressions • “War stories” and testimonies – traumatic! • Some Examples: • Being stopped for drinking water • Having security called at hotel gift shop – assumed I was not a hotel guest and that I was loitering • Being mistaken for the help numerous times while dressed in a business suit on professional travel • Being told I was standing in the wrong line © Maria Yellow Horse Brave Heart, Ph. D

Concept of Ethnic Density • People living around others like them may experience some “buffering” or protection against social effects of schizophrenia • Ethnic density as a buffer for psychotic experiences: findings from a national survey

Ethnic Density: Study in London borough Four mechanism associated with increased risk of adverse mental health outcomes among minority populations: 1. Exclusion from local networks 2. Need to rely on on geographically dispersed culturally specific services and facilities 3. perceived risk of physical and psychological intimidation 4. damaging effects of everyday racism.

Takini Wounded Knee Survivors: Tunkasila Wapaha Ska (White Lance), Joseph Horn Cloud, & Dewey Beard

Tatanka Iyotake & Sitanka Wokiksuye Sitting Bull Memorial & Bigfoot Memorial Ride 1990 Sitanka (Bigfoot)

Historical Trauma & Unresolved Grief Triba Best Practice (HTUG): Return to the Sacred Path Conf ronting Historical Trauma & Embracing Our History Understandi ng the Trauma Transcendin g the Trauma Releasing Our Pain Return to The Sacred Path

Let a hundred drums gather. It must be a time of celebration, of living, of rebuilding, and of moving on. Our warriors will sing a new song, a song of a new beginning, a song of victory. Let our warriors sing clear and loud so the heartbeat of our people will be heard by Sitting Bull and all our ancestors in the Spirit World. . Let us send to our great chief a new song to sing when he rides around the people in the Spirit World: Look at our children, They're going to live again. Sitting Bull says this as he rides. Traditional Hunkpapa Lakota Elders Council (Blackcloud, 1990) TAKINI-REBIRTH: HOPE THROUGH HTUG