Psychotherapy (Chic). Author manuscript; available in PMC 2021 Jun 21. Published in final edited form as: PMCID: PMC8216771 NIHMSID: NIHMS1714352 American Indians face pervasive trauma exposure, collective histories of communal suffering, and elevated risk for depression and posttraumatic stress disorder.
In addition to socioeconomic barriers, access to culturally responsive treatment is limited, which may compromise treatment engagement. The Iwankapiya study piloted the Historical Trauma and Unresolved Grief Intervention (HTUG), combined with Group Interpersonal Psychotherapy (IPT), to reduce symptoms of depression and related trauma and grief. The study hypothesized that HTUG + IPT would lead to greater group engagement and decreased depression and related symptoms compared with
IPT-Only. American Indian adults (n = 52) were randomized into one of two 12-session interventions, HTUG + IPT or IPT-Only, at two tribal sites: one Northern Plains reservation (n = 26) and one Southwest urban clinic (n = 26). Standardized measures assessed depression, posttraumatic stress disorder, grief, trauma, and substance use. Data were collected at screening, baseline, end of intervention, and 8 weeks postintervention; depression and group engagement measures
were also collected at Weeks 4 and 8 of the intervention. Depression scores significantly decreased for both treatments, but there were no significant differences in depression between the two groups: IPT-Only (30.2 ± 6.4 at baseline to 16.7 ± 12.1 at follow-up) and HTUG + IPT (30.2 ± 8.1 at baseline to 19.9 ± 8.8 at follow-up). However, HTUG + IPT participants demonstrated significantly greater group engagement. Postintervention, clinicians expressed preference for HTUG + IPT based upon
qualitative observations of greater perceived gains among participants. Given the degree of trauma exposure in tribal communities, these findings in a relatively small sample suggest HTUG should be further examined in context of treatment engagement. Keywords: American Indian/Alaska Native, interpersonal psychotherapy, historical trauma, depression, group engagement A paucity of research exists regarding the effectiveness
of culturally appropriate mental health treatment for American Indians (AIs); this population is also typically absent in behavioral health treatment outcome studies or clinical trials. Little evidence exists about the effectiveness of current empirically based treatments within tribal communities (Beitel et al., 2018;
Pearson, Parker, Zhou, Donald, & Fisher, 2019; Pomerville, Burrage, & Gone, 2016). AIs, a diverse collective of indigenous cultures, differ from other racial or ethnic groups in the United States due to their varied legacies of conquest in their
homelands, imposition of a foreign culture, treaty status, U.S. government obligations, and complex jurisdictional issues. These factors complicate design and delivery of effective behavioral health interventions. AIs have comparable or higher prevalence of major depression compared with the general U.S. population (Brave Heart, Lewis-Fernández, et al., 2016).
Pervasive trauma exposure among AIs increases risk for posttraumatic stress disorder (PTSD; Beals et al., 2013; Brave Heart, 1998). Moreover, AIs disproportionally face unemployment, limited income, lack of health insurance, lower educational attainment, and substance use
(Brave Heart, Lewis-Fernández, et al., 2016; U.S. Census Bureau, 2012). These factors, along with minority status, are predictors for limited behavioral health treatment engagement
(Olfson, Cherry, & Lewis-Fernández, 2009; Wang et al., 2005). Limited Indian Health Service (IHS) funding, scarcity of trained AI clinicians, suspicion and rejection of “Western” mental health treatment practices, and profound cultural differences in
subjective views of symptom etiology and approaches to their amelioration further complicate treatment engagement and retention. These factors are compounded by historical trauma (HT)—the collective, cumulative psychological wounds of massive, repeated, transgenerational group trauma (Brave Heart, 1998;
Brave Heart, Lewis-Fernández, et al., 2016; Brave Heart, Chase, Elkins, & Altschul, 2011; Whitbeck, Adams, Hoyt, & Chen, 2004). HT is an
important part of AI psychological experience and a mechanism that limits treatment engagement and contributes to ongoing depression, unresolved grief, and traumatic responses (Brave Heart, 1998, 2003;
Brave Heart, Chase, et al., 2016; Brave Heart et al., 2011; Gone, 2009;
Hartmann, St. Arnault, & Gone, 2018; Mohatt, Thompson, Thai, & Tebes, 2014). This study targets treatment engagement with AI participants. Developing effective treatments for AIs must include an understanding of the traditional cultural
worldview where time is fluid and the past is present. Contemporary individual suffering is rooted in the ancestral legacy and continues into the present. Traditionally, one cannot be separated from the influences of ancestral suffering. Time is nonlinear, circular, and simultaneous. If one heals in the present, one can go back in time and heal the suffering of the ancestors (Brave Heart, 1998).
Current AI identity includes collective bereavement and victimization, anchored in the historical past, while simultaneously possessing a resilient core. The cultural more of identifying with ancestor spirits, including their suffering, and impairment in traditional bereavement due to the United States government prohibition of traditional ceremonies, may result in a predisposition for becoming Wakiksuyapi (Memorial People;
Brave Heart, 1998). Wakiksuyapi carry compassion for the ancestors’ suffering and carry the responsibility to heal the trauma. Given the high rates of AI trauma exposure, collective generational massive group trauma, with concomitant elevated risks for depression and PTSD, examining the efficacy of treatments that target these conditions is warranted. The Iwankapiya (Healing) study combined Group Interpersonal Psychotherapy (IPT) and the Historical Trauma and Unresolved Grief Intervention (HTUG). IPT focuses on the interpersonal context for depression and the relationship of current life events to mood (Weissman, Markowitz, & Klerman, 2018). IPT’s therapeutic efficacy has been shown for depression in
non-AI groups from diverse backgrounds (Krupnick et al., 2008; Verdeli et al., 2003, 2008;
Weissman et al., 2018). HTUG complements IPT by framing depression and grief as reactions to ongoing trauma and loss that are confounded by collective internalized oppression and discrimination. It is considered a Tribal Best Practice (Echo-Hawk et al., 2011) and has been shown to reduce
self-reported symptoms of trauma, depressive and grief-related in AIs (Brave Heart, 1998, 1999, 2003;
Brave Heart, Elkins, Tafoya, Bird, & Salvador, 2012; Brave Heart et al., 2011). The initial version of HTUG was a psychoeducational group immersion experience in the Black Hills of South Dakota
(Brave Heart, 1998). The current study hypothesized that HTUG + IPT would result in greater group engagement along with decreased depression and related symptoms compared with IPT-Only. This hypothesis was based upon findings of early HTUG research, clinical experience, presentations within diverse tribal communities and their reports of perceived helpfulness. The selection of IPT versus
other treatment models was based upon the cultural importance of, and emphasis on, interpersonal relationships and interdependency. The IPT Uganda group intervention, with proven efficacy, addresses the sociocultural context in rural indigenous populations (Verdeli et al., 2003). In AI traditional cultural healing ceremonies and practices, the emotions are typically addressed
first through cathartic experiences before cognitive interpretation. We determined IPT to be culturally congruent with our population and study design. This study was funded by the National Institute of Mental Health. Multiple review boards provided approval: The Northern Plains reservation tribal research review board (RRB), the tribal college institutional review board (IRB), the Great Plains Area Indian Health Service (IHS) IRB, and
the University of New Mexico Health Sciences Center IRB. A tribal advisory panel reviewed the research protocol and intervention manuals, providing input and recommendations. The content of the group interventions, IPT-Only versus HTUG + IPT, are illustrated in Table 1 and described in more detail in the next section. Session Topics by Intervention Group
Sick role orientation re: depression and not the person’s fault Diagnose primary interpersonal problem area Focus on interpersonal issues and their influence on mood Help participants externalize depression Establish group safety and cohesion Sharing about symptoms and relationship issues Listening and sharing about symptoms and relationship
issues Historical trauma response orientation Confronting the history Group processing Psychoeducation about trauma, grief, and depression, use of American Indian DVDs Foster group identity/cohesion, safety Traditional cultural review of protective factors and indigenous ways of dealing with trauma, grief, and depression Diagnose primary historical
trauma response and interpersonal problem area Interpersonal issues and historical trauma and influence on mood Help person see mental health symptoms as part of historical trauma response and not the individual’s “fault” Cultural emphasis on listening and sharing about symptoms and relationship issues Releasing the pain: trauma graph exercise Group problem-solving and practice about interpersonal conflicts Work through grief and loss Increasing capacity to address role transitions Members help one another Members focus on changing what they can in their lives Group problem-solving and practice about interpersonal conflicts Work through grief and loss Facilitating increased capacity to address role transitions Traditional cultural releasing Members help one another Members focus on changing what they can in their lives Group ending, summarize changes in symptoms and problems Review relationship losses Discuss possible new issues that could trigger depression and how to cope with these Review group process and experiences Discuss feelings about ending and continued support among group members Group ending, summarize changes in symptoms and problems Reviewing relationship losses Discuss possible new issues that could trigger depression and how to cope with these Review group process and experiences Discuss feelings about ending and continued support among group members Transcending the trauma: Wiping the tears traditional practice and formation of
extended family kinship bond Study InterventionsIPT (group format).Although the etiology of depression is complex, psychosocial contexts contribute to triggers for depressive episodes. Three types of triggers are emphasized: grief, social role transition (e.g., marriage), or role dispute (e.g., marital conflicts). The IPT approach connects mood and life events, thus, “diagnosing” the primary focal interpersonal problem area related to the depression (Markowitz et al., 2009). As noted above, IPT was selected for reasons of cultural congruence and the availability of a group model successfully used among Ugandan tribal villagers. The AI tribal advisory and research review boards endorsed this decision. The IPT Uganda model (Verdeli et al., 2003, 2008) was modified for use with AI cultures. For example, AI cultures value interdependency and strong attachment to even distant relatives, such as aunts and uncles being viewed as parents. Manifestations of a sense of the loss of part of the self in mourning and grief rituals such as cutting one’s hair are common. Also, AI cultures are collectivist, encouraging sacrificing oneself for the good of the group, putting the needs of the group before one’s own needs oftentimes, and identifying the self in terms of the group and attachment to the group (Brave Heart, 1998, 1999). Traditionally, most ceremonies take place in a group setting, with family and community members as active participants, providing collective healing. Thus, IPT’s focus on interpersonal triggers for depression is congruent with AI cultural values and the primacy of interdependence. Too, increasing evidence exists that IPT is an effective treatment for PTSD (Campanini et al., 2010; Krupnick et al., 2008; Markowitz et al., 2015). The Iwankapiya team, thus, anticipated IPT’s relevance for AIs, given the degree of interpersonal trauma and loss, the high prevalence of PTSD (Beals et al., 2013; Manson, Beals, Klein, & Croy, 2005), and the observed complicated or prolonged grief (Shear, Frank, Houck, & Reynolds, 2005). HTUG + IPT.HTUG includes four components: (a) addressing the collective traumatic past along with grounding current trauma in the historical context, (b) providing psychoeducation about trauma and grief, (c) releasing pain through processing with others in the group, and (d) transcending trauma through therapeutic experiences and traditional healing practices including traditional songs, smudging with sweetgrass and/or sage, and talking circles (Brave Heart, 1998, 2003; Brave Heart et al., 2011, 2012). The theoretical underpinning of HTUG is the conceptualization of historical trauma response (HTR): a constellation of features in reaction to the massive group trauma across generations, which may include symptoms of depression and PTSD, along with unresolved, prolonged, or complicated grief. The HTR is the counterpart to the “sick role” in IPT in terms of reducing self-blame and focusing on causality of these affects, thereby normalizing HTR features and de-stigmatizing symptoms. However, in contrast with IPT, HTUG does not use the term “sick,” which can be experienced as victim blaming to AIs, given the history of racism and oppression. Rather, HTR frames these symptoms as reactions to collective and generational traumatic events in which personal or idiosyncratic trauma are embedded and linked. The original HTUG and HTR were developed by AI clinicians and clinical researchers from both qualitative study and immersion in their tribal communities (Brave Heart, 1998; Brave Heart, Chase, et al., 2016). Utilizing the language of HTR in HTUG + IPT rather than the “sick role” did not dilute IPT for the HTUG + IPT model but rather culturally adapted the concept to better-fit AI participants. In addition to developing HTUG and also having training in IPT, the lead authors consulted regularly with the developers of IPT and senior IPT clinical researchers to ensure fidelity to the underpinning of this approach (Markowitz et al., 2009). A tribal advisory panel consisting of individuals from both sites also reviewed the manualized intervention protocols to ensure the integration of IPT-Only and HTUG + IPT for cultural appropriateness. The tribal advisory panel was especially important in ensuring culturally specific practices, given the lack of evidence base for interventions with AIs (Brave Heart, Lewis-Fernández, et al., 2016). In summary, the integration of HTUG + IPT focused on the parallels of HTUG with IPT’s interpersonal triggers and the sick role concepts, as described earlier. Table 1 illustrates components of the intervention models. HTUG + IPT begins with orientation and psychoeducation about HT and HTR; AI traditional cultural values, strengths, and practices; and diagnosing the primary interpersonal problem. In contrast to IPT, rather than the sick role, participants’ primary HTR features, including depressive symptoms, are identified by the group members. Distinct for HTUG + IPT, the HTUG component includes traditional cultural practices for releasing emotions and self-soothing such as smudging with sage or sweetgrass, traditional songs, and reviewing traditional tribal values such as compassion, respect, humility, and generosity, as well as developing the capacity for tolerance and patience, courage, and wisdom. Due to the generational oppression of AIs and the past prohibition of the open practice of traditional ceremonies, this conceptualization of HTUG is crucial to facilitate the release of self-blame and lowered self-esteem. Traditional AI cultures required self-sacrifice for the good of the nation and development of ego strengths including overall impulse control, capacity for delayed gratification, and altruism (Brave Heart, 1998; Brave Heart, Chase, et al., 2016). To maintain fidelity to the group IPT model, as evident in Table 1, only HTUG + IPT included a focus on the collective historical traumatic past, cultural self-soothing practices, and specific cultural content. Both treatment arms focused on group cohesion, but HTUG + IPT also focused on group identity, which is culturally congruent for tribal communities and an important part of collective healing that HTUG addresses. For AI tribes, individual identity develops within the context of a collective identity that is formed around the values of compassion, respect, humility, generosity, putting the good of the tribe first, developing a great mind, courage, and wisdom. In tribal communities, this is expressed with a traditional decision-making process that is guided by consensus and collectivist framework where the “good of the whole” is paramount. A sense of belonging and attachment to one’s identity and community, both tribally specific and with other tribes, prevents isolation. Toward this end, establishing group cohesion in tribal communities centers around enhancing collective identity as found with other populations (Marmarosh & Corazzini, 1997). Enhancing group identity included use of original psychoeducational materials (Brave Heart, Chase, Sierra, Kills Straight, & Lockhart, 2002) focusing on collective AI values as well as shared collective HT in the initial sessions (Table 1). This content included the prevalence of abusive compulsory government operated or church run boarding school placement, forced separation from families, and surviving rampant physical and sexual abuse in these schools. The impact of this collective traumatic history affected not only survivors but also their descendants (Brave Heart, 1998, 1999). As survivors, these shared collective generational experiences fostered both group identity and cohesion. Distinctive features grounded in traditional AI cultural norms in addition to shared traumatic history required adaptations. For instance, common measures of group cohesion may include direct eye contact, tolerance for close personal space, and speaking up (Burlingame, McClendon, & Yang, 2018). In contrast, AI customs often include comfort with silence, deliberation before speaking, polite physical space, and respectful avoidance of direct eye contact depending upon gender and age differences, particularly among older AIs. A cultural predisposition exists for a collective group identity within the extended kinship network, with protocols governing relatedness. Congruent with fostering group cohesion, HTUG participants come together to address their mutual traumatic past grounded in the collective HT. Participants bonded around the intention of healing depression, PTSD, and prolonged grief through first addressing HT and HTR. Cultural values of relatedness include Mitakuye Oyasin (we are all related) fostering culturally congruent group cohesion. The guiding principles of Woope Sakowin (Seven Laws) were used as ground rules. Participants.The study took place in two diverse tribal communities: one Northern Plains reservation site (NP) and one Southwest urban clinic (SW). AIs aged 18 and over were randomly assigned to each treatment group. This age range was congruent with the intergenerational focus of HTUG, endorsed by the tribal RRB, and accepted by our Data Safety Monitoring Board. Those approached for participation entered outpatient behavioral health clinics at the two tribal sites and had a positive screen for depression based on the Hamilton Depression Scale 24 (HAM-D; Miller, Bishop, Norman, & Maddever, 1985) or the Patient Health Questionnaire (Kroenke, Spitzer, & Williams, 2001), a standard clinical assessment interview to assess appropriateness for inclusion in the study. Exclusion criteria included a positive screen for current serious mental disorders (e.g., schizophrenia, bipolar disorder, other psychosis), impaired cognitive ability, or acute suicidal/homicidal risk. Also excluded were those with active substance use disorder (SUD) that was more severe than “mild,” as defined by the Diagnostic Statistical Manual, Fifth Edition (DSM‒5; American Psychiatric Association, 2013). SUD in remission and nicotine use were not bases for exclusion. Ninety-five (95) potential participants were screened; as described in the Results, sample demographics may be found in Table 2. Table 2Demographics and Baseline Characteristics of Patients Randomized to Group IPT or HTUG + IPT Treatments
Study design.The treatment intervention was conducted in two waves of IPT-Only and HTUG + IPT at each site, at two different time points. To have optimal size for clinical intervention groups, in keeping with previous IPT studies, the target sample size was 64 participants (Krupnick et al., 2008). However, only 52 of those screened met eligibility criteria and were enrolled in the study (Figure 1). Reasons for ineligibility included acute or chronic SUD, acute suicidality, psychosis, and personality disorders. Participants were stratified into four strata: (a) no antidepressant, antianxiety, or psychotropic medication, and no SUD; (b) only antidepressant, antianxiety, or psychotropic medication, and no SUD; (c) mild SUD only (for alcohol and/or marijuana); and (d) both mild SUD and antidepressant, antianxiety, or psychotropic medication. Medication usage and any changes in ongoing treatment were tracked. An SAS random number–generating function was written to randomly assign participants to treatment conditions within each stratum as they entered the study. Although this randomization was designed to avoid alternate assignment and long runs of assignment to the same group, attrition before the study started resulted in unequal numbers in the groups due to changes in participant circumstances such as a move, divorce, or other socioeconomic factors. For the IPT-Only group, the final sample size was 23 and for the HTUG + IPT group, 29.  Consort diagram of inclusion and randomization into Iwankapiya study. IPT = interpersonal psychotherapy; HTUG = Historical Trauma and Unresolved Grief Intervention. Therapists.Lack of trained AI mental health professionals is a significant issue in providing culturally informed and responsive mental health services. To increase the mental health treatment capacity within the two tribal locations, senior clinicians were paired with a trainee or less experienced clinician (often community providers or tribal college students) who helped cofacilitate the group sessions. Due to limited numbers of available male clinicians, most providers were female, except for one AI male professional counselor. Providers included PhD-level AI and Caucasian licensed clinicians (psychologists, clinical social workers, and nurses), masters-level counselors, and a supervised AI social work student intern. Two of the AI providers were also Navy veterans. AI providers were representative of the local or similar tribal populations. All clinicians received supervision and consultation via conference calls throughout the study (Falkenström, Markowitz, Jonker, Philips, & Holmqvist, 2013). Given the legacy of research abuses of AIs (Mello & Wolf, 2010) and to be culturally responsive to concerns about privacy and confidentiality, sessions were not tape–recorded, as this could have limited participant sharing and disclosure. Our tribal RRB concurred with this decision. Therapists were assigned to provide either HTUG + IPT or IPT-Only to limit bias or contamination across treatment groups (Falkenström et al., 2013). All treatment providers were trained before the start of the study by one of the original developers of IPT. Only providers assigned to deliver HTUG + IPT were trained in HTUG components and integration of the models. Ongoing follow-up training and clinical supervision were conducted over the course of the study. In Wave 1, the therapists were non-Hispanic White for IPT and AI therapists for HTUG + IPT. For Wave 2, there was one non-Hispanic White therapist for IPT paired with an AI therapist; for HTUG, two AI therapists facilitated at both sites. Fidelity checks for the two treatment conditions occurred at two observational time points by clinicians not involved with the treatment but who were oriented to the models. The observational guide used was developed in collaboration with expert consultants. Dosage.Participants were asked to attend 12 weekly 2-hr sessions. Treatment was generally completed within 16 weeks due to weather or holiday-related interruptions. Patients who completed at least four sessions were included in the analysis, comparable with other psychotherapy studies (Krupnick et al., 2008). Treatment conditions.IPT-Only and HTUG + IPT were compared across the two randomized groups. For both groups, IPT integrated the Group IPT approach utilized in Uganda (Table 1). HTUG was modified from an intensive 4-day, retreat approach (Brave Heart, 1998) into a 12-session intervention and incorporated IPT-Only. The HTUG + IPT manual comprised 12 modules that included psychoeducational content, facilitator instructions, and participant handouts. It was augmented with audiovisual media such as the Celebration of Survival: The Takini Network (Brave Heart et al., 2002). Group IPT was modified for minor cultural and geographic context only (i.e., for U.S. tribal communities vs. Ugandan tribal villages). IPT group size in other studies ranged from three to eight participants to allow time for processing depressive, trauma, and grief symptoms, interpersonal issues, and relevant history (Krupnick et al., 2008; Verdeli et al., 2003). In the Iwankapiya study, groups on average ranged from five to eight participants per group. Equal dosage was provided in both treatment conditions, for example, the same number and length of sessions. Therefore, HTUG + IPT had more treatment content to cover than IPT-Only groups. IPT-Only focused on current and recent interpersonal issues. In contrast, HTUG + IPT focused on AI collective massive group trauma, historical unresolved grief, modern day traumatic exposure and grief, as well as current relationship conflicts and linking current interpersonal issues as appropriate to the collective historical context to reduce stigma and isolation. HTUG + IPT also includes a “wiping of tears” exercise based upon a traditional grief resolution ceremony developed with a Lakota healer for use in the original HTUG in the last session (Brave Heart, 1998). MeasuresThe Hamilton Depression Scale‒24 (HAM-D24; Miller et al., 1985) is a version of the most widely used clinician-administered depression rating scale, frequently used in IPT research. The HAM-D24 rates the severity of, and change in, major depression symptoms. It was administered at screening (T1) and repeated at Weeks 4, 8, and 12 (T2), and at Week 20 follow-up (T3). The Patient Health Questionnaire (Kroenke et al., 2001) is a nine-item depression scale utilized in IHS clinics to quickly assess symptoms and functional impairment, to make a tentative diagnosis of depression and to help select and monitor treatment based on a severity score. A severity score of 10 indicated a positive screen for inclusion in the study, provided other criteria were met, as outlined under Study Design. The Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, De la Fuente, & Grant, 1993), a brief assessment for excessive drinking with high internal consistency, validity, and reliability, was used at screening (T1) and repeated at 4 and 8 weeks. In addition, a clinical interview and standard psychosocial diagnostic assessment were conducted. This included: presenting problem(s), history of the problem(s), psychiatric and medical history, psychosocial history, prior treatment, suicidality, mental status exam including hallucinations and delusions, and diagnosis. Patients with diagnoses not meeting the inclusion criteria (e.g., acute suicidal risk, psychotic disorders, and personality disorders) were referred for other treatment and acute care as indicated. The Indigenous Peoples Survey (Brave Heart et al., 2011) was designed to collect data in both reservation and urban tribal communities on the experience and impact of collective group trauma, lifetime trauma exposure, racism and discrimination, as well as tribal cultural identity, values, practices, and spirituality. The Indigenous Peoples Survey incorporates the following measures:
Reliability of outcome measures was high when assessed using Cronbach’s α: HAM-D24: 0.89, CMGQ: 0.90, PCL-C: 0.95, HLS: 0.92, HLAS: 0.92, FSSQ: 0.89, and Lakota Grief Experience: 0.76. The Group Engagement Measure (GEM; Macgowan, 2006; Macgowan & Newman, 2005), a comprehensive observational measure assessing various dimensions of participant engagement, was completed by the research team. GEM subscales include attendance, contributing, relating (to group facilitator and group members), contracting, and working (on own problems and on others’ problems). The 27 items on the Likert scale range from 1 (rarely or none of the time) to 5 (most or all of the time). Higher scores (with 5 being the uppermost score) show stronger group engagement. The GEM has demonstrated good internal consistency as well as tested construct and predictive validity. In this study Cronbach’s α = 0. 91 for GEM. The GEM was administered at Weeks 4 and 8. Data Analytic StrategyParticipant characteristics by treatment arm (IPT-Only vs. HTUG + IPT) were summarized as frequencies and percentages or as means and standard deviations or 95% confidence intervals (CIs). We assessed whether participant subgroups had different characteristics using Fisher’s exact tests and nonparametric Wilcoxon’s Rank Sum tests for categorical and continuous variables, respectively. The study design included measurements nested within participants and participants nested within therapy groups. We used mixed model regression, sometimes called hierarchical linear model analysis, to assess whether changes in measures over time were different for IPT and HTUG + IPT while accounting for the nested study design (Raudenbush & Bryk, 2002; Singer & Willett, 2003). In these models, individual change trajectories were modeled at Level 1 (Equation 1), and variation between participants was modeled at Level 2 (Equation 2). Level 1: Yti=β0i+β1i(Time ti)+εti (1) Yti = measurement for participant i at time t, β0i = intercept for participant i, β1i = slope for linear change in time for participant i, Timeti = measurement time period, and ɛti = residual variation for participant i Level 2: β0i=γ00+γ01(HTUG)+u0i β1i=γ10+γ11(HTUG)+u1i (2) γ00 = population average of Level-1 intercepts for IPT arm participants, γ01 = population average difference in Level-1 intercepts for HTUG + IPT arm participants, HTUG = indicator variable: 1 = HTUG + IPT arm, 0 = IPT arm, u0i = random Level-2 residuals for individual i intercept differences from population average intercept, γ10 = population average of Level-1 slopes for IPT arm participants, γ11 = population average difference in Level-1 slopes for HTUG + IPT arm participants, and u1i = random Level-2 residuals for individual i slope differences from population average slope. Key features of this setup (Model A) are that fixed effect coefficients for intercepts and slopes model the variation by study arm at Level 2: γ10 is the aggregate, population average change over time for the IPT arm, and (γ10 + γ10) is the population average change for HTUG + IPT participants. The γ11 coefficient estimates the size of intervention effects (Slope × Condition interaction). Nesting of participants in therapy groups was not modeled explicitly but was absorbed into Level-2 variation of intercepts (u0i). To assess sensitivity of γ11 coefficient estimates to therapy group and other factors we fitted a second, more fully adjusted set of models to account for therapy group, participant strata, and site (Model B). In Model B, we added fixed effect coefficients effects to Model A for additional Level-2 effects on intercepts: participant strata (γ02, γ03, γ04) and site/therapy group (γ05, γ06, γ07). With our study design, effects of therapy group were not completely separable from site. Ordinal continuous time was used in models with time centered at T2 to force the difference between intercepts (γ01) to be estimated at the end of the intervention: T1 (baseline) = ‒3, Week 4 = ‒2, Week 8 = ‒1, T2 = 0, and T3 = 1. Supplemental repeated measures analyses using categorical time periods were used to estimate change from T1 (baseline) to T2 and to T3 and whether these differences varied by condition (Time Period × Condition interaction). Factors affecting dropout were assessed using Fisher’s exact tests, Wilcoxon’s Rank Sum tests, and log-Binomial regression analyses. Correlation analyses (Pearson and Spearman) were used to assess whether GEM was associated with individual change. A supplemental multiple imputation analysis was conducted to assess whether conclusions about HAM-D24 were sensitive to missing data. In multiple imputation analysis, m synthetic data sets are generated where missing values are replaced with predicted values based on an appropriate model. The m complete data sets are then analyzed using standard methods, and results from each of the m analyses are combined to make inference that accounts for variability across imputations (Little & Rubin, 2002; Rubin, 1987). We set m equal to 10 and imputed missing items for HAM-D24 assuming a using a predictive mean matching approach. SAS Version 9.4 was used for analyses (SAS Institute, 2014). ResultsTable 2 shows that there were no significant demographic differences between the two treatment arms (IPT vs. HTUG + IPT), including number of participants from each site. Overall 79% of participants were female with average age equal 43.6 years (SD = 13.7), 51% had at least some college, and 26% were currently married. Unemployment was high overall (48%), and income was low (62% with annual income <$15,000). The clinical measures showed few differences. The assessment of prolonged grief (CMGQ) was higher in the HTUG + IPT group (20.8 ± 6.7 vs. 19.9 ± 8.7, p = .01). The IPT group reported marginally poorer functional support (FSSQ 23.1 ± 7.2 vs. 19.0 ± 7.5, p = .06). In further examination of the HT measures, loss and grief from CMGQ (data not shown), among the 52 participants, 41 (81%) had lost at least one close relative or friend, and 31 (60%) had experienced multiple losses in the past 2 years. The most common personal losses were of a child (27%) and parent (24%). The most common causes of death were health problems (42%), traumatic events (20%), natural causes/old age (15%), and suicide (12%). Patient strata were similarly distributed across treatment arms (p = .99). Table 3 shows study measures by time period and has coefficients that assess change by study arm. Linear change estimates per study period are shown in the Within Condition Slope column for each measure and condition. Coefficients for the Slope × Condition interaction (γ11) and associated t statistics provide evidence for whether linear slopes were different for IPT and HTUG + IPT arms. HAM-D24 depression scores significantly improved (decreased) for both treatments. The slope estimate per study period for IPT was ‒3.07 (95% CI [‒4.44, ‒1.69]) compared with ‒2.60 (95% CI [‒3.75, ‒1.45]) for HTUG + IPT; however, the small difference between linear slopes was not significantly different for Model A or for Model B (Table 3). At 20 weeks, nearly 58% of participants showed 20% or more improvement in HAM-D24, but 10% had scores that were ≥20% worse. Change for NP HTUG + IPT was less pronounced, ‒1.19 (95% CI [‒2.64, 0.27]), than for IPT, ‒2.55 (95% CI [‒4.29, ‒0.82]), and compared with the SW, IPT: ‒3.16 (95% CI [‒4.47, ‒1.85]), HTUG + IPT: ‒3.79 (95% CI [‒5.01, ‒2.56]). The GEM score for HTUG + IPT was significantly higher relative to IPT-Only at Week 8 (Wilcoxon’s test p = .012), and amount of change from baseline to the end of the intervention was significantly correlated with the amount of GEM (Table 4, Spearman correlation = ‒0.34 p = .11). After accounting for the study design, individual predicted linear change slopes were not correlated with GEM (Table 4). Table 3Study Variables by Measurement Period and Intervention Arm (Condition) With Hierarchical Linear Model Coefficients for Linear Trends and Tests for Homogeneity of Time Trends (γ11)
Table 4Correlation Between Group Engagement Measures (GEM) With Change in Outcome Measures and With Predicted Random Effects for Linear Slopes (u1i) From Model B
Improvement in CMGQ scores was not different for the two treatments (p = .788) but improved when the groups are combined (slope = ‒1.05 per period, 95% CI [‒1.73, ‒0.38]; data not shown). At 20 weeks, 30% of participants showed 20% or more improvement in CMGQ, and 16% had scores that were ≥20% worse. PCL-C scores decreased significantly for the IPT treatment (‒2.38, 95% CI [‒4.09, ‒0.67]) but not for HTUG + IPT (0.01, 95% CI [‒1.45, 1.47]). At 20 weeks, nearly 21% of participants showed 20% or more improvement in PCL-C overall, and 11% had scores that were ≥20% worse. Among HTUG + IPT participants, 17% improved, and 21% showed deterioration, whereas among IPT-Only participants, 26% improved, and no participants showed deterioration. Post hoc analyses showed that participants in HTUG + IPT treatment whose PCL-C scores increased rather than decreased over time tended to have low group engagement scores (GEM, Pearson correlation = ‒0.36 p = .056; data not shown). Improvement in HLAS scores was associated with greater GEM (Table 4), although there was no difference in the amount of improvement for the two treatments. Other measures did not show significant change over the study. At 20 weeks, 17% of participants showed 20% or more improvement in HLAS, and 17% had scores that were ≥20% worse. For HLS at 20 weeks, 17% of participants showed 20% or more improvement, and 19% had scores that were ≥20% worse. At 20 weeks, 15% of participants showed 20% or more improvement in FSSQ, and 19% had scores that were ≥20% worse. At 20 weeks, 2% of participants showed 20% or more improvement in Lakota Grief Experience Questionnaire, and 10% had scores that were ≥20% worse. HAM-D24 analysis with multiple imputation of missing values also failed to detect slope differences between treatment groups in HAM-D24 scores. We conducted additional analyses to understand dropout. Engagement scores were lower among participants dropping out before the T2 measurement (Wilcoxon’s test p < .001), and the relative risk of dropout decreased by 0.63 (95% CI [0.53, 0.76] p < .001) for each unit increase in the GEM score. Younger participants were also more likely to drop out by T2 (Wilcoxon’s test p = .042); however, the age bias did not persist to T3 (8 weeks postintervention; Wilcoxon’s test p = .216). When we considered gender, education, marital status, income, employment status, affiliation, site, intervention arm, and participant strata, only the two confounded factors site (Fisher exact p = .040) and tribal affiliation (Fisher exact p = .045) were associated with dropout, with 50% dropout at NP compared with 19% for SW site. As seen in Table 4, the GEM was associated with significant improvement in HLAS individual predicted slopes (rs = —0.32 p = .020), but not for other measures. Engagement scores at 8 weeks was 4.0 ± 0.7 among HTUG + IPT participants compared with 3.2 ± 1.3, adjusted mean difference 0.87; 95% CI [0.20, 1.54], p = .012. Supplemental analyses using categorical time and using multiple imputations did not provide substantially different results. Not shown here but of note, there were also no reported changes in medications across the course of the study for participants who entered the study on prescribed medications for depression or other conditions that could impact mood. DiscussionIwankapiya addressed gaps in scientific knowledge in the following ways: (a) focusing on AIs, a severely underrepresented population in psychotherapy research, in two disparate tribal locations with different tribal cultures; (b) training AI providers to deliver the pilot intervention; and (c) contributing to understanding of the feasibility of culturally grounded engagement and evidence-based treatment with AIs. Iwankapiya contributed to the clinical practice and research literature, advancing knowledge about treating AI patients suffering with depression, trauma, and related symptoms. AIs are unrepresented in clinical intervention studies both as research participants and as researchers, especially Principal Investigators. All too often, the imposition of evidence-based treatments developed with non-AI populations may not be culturally appropriate, and these are often experienced as oppressive, lacking goodness of fit, irrelevant, and offensive (Brave Heart, Chase, et al., 2016; Gone, 2009). The results of this pilot study were promising, given the reduction in depressive symptoms over time for both treatments. In examining the potential relationship between GEM scores and retention, no statistically significant association was found. This may be due to the timing of the collection of GEM starting at Week 4, thus, representing retention among a group of people who have already participated for 4 weeks. Future efforts should investigate the relationship of low group engagement with early dropout. The fact that the scores on the GEM were greater for the HTUG + IPT suggests greater engagement and bonding for group participants, which could have implications for treatment benefits. Such findings are not unexpected: The importance of cohesion in group therapy is widely recognized (Burlingame et al., 2018). One aspect of HTUG is the emphasis on traditional tribal cultural values and practices, which are congruent with culturally grounded self-soothing for symptoms of trauma, grief, and depression. Another tenet of HTUG is the validation of the collective trauma, which facilitates externalization of symptoms, thereby reducing self-blame and mitigating ongoing internalization. Older participants verbalized that until the HTUG + IPT group, no one had addressed boarding school trauma in past behavioral health treatments and expressed relief as well as a sense of a weight being lifted. Clinical providers expressed preference for HTUG + IPT as they perceived and observed substantial engagement and retention of participants and appreciated the inclusion of the cultural content and validation of the collective history and HTUG approach. This perception was not limited to the AI providers; the Caucasian providers expressed a preference for HTUG + IPT after the study ended, based upon their observations of positive changes in mood among HTUG + IPT participants over time; they also talked about wanting to use just HTUG alone in the future. One limitation in interpreting the results is the relatively small sample size. Most of the comparisons failed to reach statistical significance. With this sample size, the detectable effect size for the difference between the two groups is 0.9. This research was designed as a small sample study to develop methodology for community-based healing interventions for historical trauma and unresolved grief, along with related behavioral health symptoms, for example, depression, PTSD, and complicated or prolonged grief among AIs. The interventions required small groups, congruent in size with other IPT studies (Krupnick et al., 2008), to maximize benefits of the therapeutic process and allow sufficient time for group participants to share. Despite the challenges, the results of this study show the feasibility of instituting and completing the intervention to obtain quantitative and qualitative data; future studies with more treatment groups could allow for a larger overall study sample size to detect small or medium effect size. Salient characteristics of many AI cultures include the intensity of attachment to large extended kinship networks and the continued relationships with the deceased in the spirit world through ceremonies. Although these networks can enhance resilience and social support, mortality rates result in frequent loss of kin and communities being in constant states of mourning. AIs, enacting a traditional responsibility to protect the homeland, often have the highest rate of enlistment in the military of any racial or ethnic group in the United States and face high combat exposure risk, given enlistment for military service with the greatest risk for combat deployment (Bassett, Buchwald, & Manson, 2014; Department of Veterans Affairs, 2012). As described previously, HTUG + IPT had more content to cover than IPT-Only; specifically addressing collective and individual trauma histories and focusing on treating participant trauma responses to collective and idiosyncratic grief. Accordingly, IPT-Only was expected to show a steeper slope on the depression measures; instead the two intervention arms were largely equivalent. Although reviewing one’s traumatic past can trigger ambivalence and anxiety, it can be validating and cathartic. As discussed in other group therapy studies, group members may feel worse before feeling better as they learn to tolerate affect (emotions) associated with traumatic memories as they progress through the healing process (Tasca, Maxwell, Faye, & Balfour, 2017). HTUG + IPT incorporates cultural self-soothing and ego-enhancing strategies. Participants asked to repeat HTUG + IPT, as they found the groups essential to coping and overcoming the challenges they faced on a regular basis. In addition, some participants expressed interest in being trained to be peer cofacilitators as part of sustainability. Significantly greater barriers existed for NP participants, such as travel distances, transportation barriers, old vehicles, poor cell phone coverage, or cell phones frequently disconnected due to lack of funds, which may have contributed to the higher dropout rates. NP study team members especially had to navigate multiple hurdles such as long distances, limited resources, and their own simultaneous ongoing family and community trauma. Greater treatment engagement may indicate increased potential for the effectiveness and quality of the therapeutic relationship. The group provided a nurturing holding environment, containment for powerful affects, and enhanced the capacity of the participants to incorporate treatment benefits. Providers observed group affinity, cohesion, bonding with others with whom group members identified, and shared experiences; participants verbalized and manifested attachment through receiving and offering support to other group members. The Iwankapiya pilot study demonstrated promise for reducing depressive symptoms, trauma, and grief responses. However, implementation challenges included limited treatment resources in tribal communities facing overwhelming ongoing trauma and tragic deaths. Recommendations include increasing treatment resources and accessibility for tribal communities, increasing tribal behavioral health provider training and support, and strengthening grassroots community aides to facilitate early intervention. Given the degree of trauma exposure in tribal communities, the Iwankapiya findings in a relatively small sample suggest HTUG should be further examined in a larger study in the context of minimizing barriers to treatment and examining the influence of treatment engagement. Moreover, focus is needed on increasing provider skill development and support in delivering the intervention. Iwankapiya clinicians delivered the interventions without any additional compensation on top of burdensome schedules and significant trauma exposure in their clinical roles as well as in their own families and communities. Future research should include additional training, increased staff resources, and ongoing supervisory, administrative, and emotional support. Clinical Impact StatementQuestion:Does the Historical Trauma and Unresolved Grief Intervention (HTUG) combined with Group Interpersonal Psychotherapy (IPT) result in lower depression and increased treatment engagement than IPT alone? Findings:The Iwankapiya study suggests that American Indian adults with trauma histories are more engaged when therapy includes an emphasis on collective trauma and cultural values and practices, as in the HTUG component; depression scores decreased comparably for both treatment conditions groups. Meaning:Integrating the cultural and historical context increases treatment engagement, contributing to greater capacity for treatment gains such as reducing depression, trauma, and related symptoms. Next Steps:Given the degree of trauma exposure in tribal communities, these findings suggest HTUG should be further examined in a larger group in the context of minimizing barriers to treatment and examining the influence of treatment engagement. AcknowledgmentsThis study is supported by National Institutes of Health, National Institute of Mental Health (R34MH097834). The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the U.S. government. The authors wish to acknowledge the approval and encouragement from the Oglala Sioux Tribe Research Review Board, the Oglala Lakota College Institutional Review Board, Great Plains Area Indian Health Service Institutional Review Board, First Nations Community HealthSource Behavioral Health, and the University of New Mexico Human Research Protection Office. Contributor InformationMaria Yellow Horse Brave Heart, Department of Psychiatry and Behavioral Sciences, University of New Mexico. Orrin Myers, Department of Family and Community Medicine, University of New Mexico. Betty Skipper, Department of Family and Community Medicine, University of New Mexico. Cheryl Schmitt, Department of Family and Community Medicine, University of New Mexico. Josephine Chase, Department of Social Work, Oglala Lakota College. Jennifer Elkins, School of Social Work, University of Georgia. Jennifer Mootz, New York State Psychiatric Institute, Columbia University. V. Ann Waldorf, Department of Psychiatry and Behavioral Sciences, University of New Mexico. References
Which of the following terms is defined as taking on the cultural ways of the dominant culture?assimilation, in anthropology and sociology, the process whereby individuals or groups of differing ethnic heritage are absorbed into the dominant culture of a society.
Which of the following term refers to the ability to stretch under pressure but not break?Materials and Their Weldability
Ductility is the ability of a material to be drawn or plastically deformed without fracture. It is therefore an indication of how 'soft' or malleable the material is. The ductility of steels varies depending on the types and levels of alloying elements present.
In what is referred to by some as extreme mundane environmental stress?In what is referred to by some as "extreme mundane environmental stress," African Americans often express the. effects of modern day racism as. self-doubt.
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Brave heart’s intervention with the lakota sioux resulted in all of the following except
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