Reconsidering Culturally Competent Approaches to American Indian Healing and Well-Being

Abstract

There is an urgent need to eliminate mental health disparities experienced by American Indians and Alaska Natives (AI/ANs). Service providers and researchers often address these disparities by focusing on low rates of participation in Western mental health services. In part, this reflects limited understandings of the sociopolitical and historical context of AI/AN mental health problems. Furthermore, this emphasis fails to recognize the importance of emic understandings of locally resonant coping strategies, healing, and treatment. In this article, we describe (a) a study designed to address these gaps, (b) findings related to the importance of land and place, and (c) a community-university collaboration to translate these findings into meaningful change within one Diné community. Connections to the land were an important cultural strength on which to build efforts to promote mental health. Thus, effective treatment might involve more in-depth understanding of cultural processes through which healing occurs and well-being is maintained.

American Indians and Alaska Natives (AI/ANs)¹ experience higher rates of psychological distress than the population of the United States as a whole (Manson, Beals, Klien, Croy, & Team, 2005; National Center for Health Statistics, 2004). The authors of several large studies have identified AI/AN lifetime prevalence rates that range from 35% to 54% for any mental health disorder (Beals et al., 2005; Duran et al., 2004; Whitbeck, Hoyt, Johnson, & Chen, 2006). In 2009, almost 30% of AI/ANs were younger than 18 (U.S. Department of Health and Human Services Office of Minority Health, 2012). Although there is wide diversity in cultures, experiences, communities, and contexts of development of AI/AN youth, as a group, they have the highest rate of suicide among 15 to 24 year olds in the United States (National Center for Health Statistics, 2004).

These disparities have developed within a colonial context of ongoing oppression, cultural and historical loss, high rates of victimization and violence exposure, poverty, and other daily and chronic stressors. Thus, it is important to recognize and explore what O’Nell (1996) called “socially produced demoralization” (p. 7) and the “cultural and historical contextualization of psychopathological experience” (p. 10) among AI/ANs. O’Nell focused on the experience of depression within a particular AI/AN community and found that depression manifested not merely as symptoms within an individual, but more broadly as a reflection of the oppressive history, disrupted social relations, and loss of identity of AI/AN people.

Many others have conceptualized this and related phenomena as historical trauma, which Brave Heart (1998) defined as cumulative emotional and psychological wounding across generations including the lifespan. Others have also highlighted that understanding AI/AN history and the resulting intergenerational transmission of trauma is essential to healing for AI/AN people (Brave Heart, 1998; Duran & Duran, 1995; Evans-Campbell, 2008). Furthermore, AI/AN mental health problems cannot be understood without situating them within a discussion of history, culture, identity, and spirituality (Alcantara & Gone, 2007).

At the same time, there is growing acknowledgment among Western mental health providers and researchers regarding what many AI/AN people have been keenly aware of for generations—namely the “profound cultural divergences in Western professional and American Indian therapeutic traditions” (Gone, 2008, p. 369). However, there is less consensus about effective ways to address this discrepancy within behavioral health systems in the United States. Many scholars have eloquently described these differences for more than 40 years (Deloria Jr., 1969; Gone, 2004; LaFromboise, 1988). Given that AI/ANs experience large disparities in mental health (Indian Health Service, 2011) and that the United States government is obligated by treaties to provide access to health care for AI/ANs (U.S. Commission on Civil Rights, 2003), it is imperative to continue to explore prevention and treatment efforts built on meaningful American Indian traditions for healing and well-being.

Although AI/AN community members’ treatment and healing preferences vary, their response to culturally incongruous services is often framed as a lack of treatment engagement (Gone, 2004; Johnson & Cameron, 2001). In part this is because the mental health services literature is limited in terms of understanding emic perspectives of ways to cope with mental health challenges, what healing and treatment mean, and what locally driven efforts or partnerships have been developed that attempt to build on the strengths of Western and Indigenous healing traditions. Without this understanding, it is unlikely that service providers or researchers will be successful in partnering with AI/ANs to connect community members with or create meaningful treatment and healing. Furthermore, without a recognition of the root causes of many mental health problems experienced by AI/ANs, many treatment and healing efforts will be misdirected at individuals rather than promoting community-level healing through cultural reclamation and revitalization and through addressing social, economic, and political inequities.

Most mental health treatments and the “evidence-base” for them have been developed within a Western colonial context, meaning that the implicit values, assumptions, and methods serve to subjugate the epistemological frameworks and healing traditions of Indigenous peoples (Smith, 2012). Thus, it is important that researchers employ a critical Indigenous perspective and methodologies to develop, implement, and research approaches to addressing the mental health challenges experienced by AI/AN people. Smith (2012) has also emphasized that it is essential to explore how colonization and related negative consequences were and continue to be experienced differently within particular local Indigenous communities.

Diné Culture and Mental Health

Our view of culture is a processual one that reflects a multitude of beliefs and practices (sometimes contradictory) that are a result of millennia of development, exchange, and constant modification in the face of changing conditions. Culture cannot be applied in a broad swath to encompass one group of people—e.g., the Diné (Navajo)—in the same way across time and space. In short, we recognize that, among the Diné people, varying axes of identity—age, gender, sexuality, health status, sexual orientation, geographic location, adherence to various religious or spiritual traditions, engagement in market economics—all impact one’s sense of self and community. Our view of culture is influenced by practice theory (Ortner, 2006), which emphasizes culture as a mobile object. Culture is constantly co-constructed by people and institutions, highly politicized, and inextricably bound up with power relations.

Waldram (2004) has illuminated the ways in which scholars’ descriptions of Indigenous people are shaped by Western assumptions and models of illness and health and by processes of essentialization that ignore the great diversity of Indigenous cultural beliefs and practices. He also described the negative implications these have for treatment. Psychologists and psychiatrists have increasingly recognized that culture plays an important part in understanding mental illness and that mental health providers can learn much about treating patients through taking seriously the work of Indigenous diagnosticians and healers (see, for example, Lewis-Fernandez & Kleinman, 1995). Thus, as Das, Kleinman, and Locke (1997) have shown through their work on illness, health and social suffering, developing an emic understanding of well-being and suffering is critical to research and interventions that aim to relieve social suffering.

The literature on Diné health and healing has been greatly influenced by the work of Csordas (2002), including the Navajo Healing Project (Csordas, 2000). One of Csordas’s important insights was the eclecticism of various religious healing traditions for Diné people, including traditional, Native American Church, and Christian healers of multiple denominations. In addition, Csordas revealed the syncretic use of these traditions, noting that many people use them serially or congruently. A third important finding was that healing is most often described as a process, not as the result of one intervention, either biomedical or religious.

Finally, Csordas emphasized the importance of talking to people as part of the healing process. The researchers behind the Navajo Healing Project explicitly did not privilege a biomedical perspective:

Indeed, restricting our attention to the principal modes of religious healing emphasizes that in Navajo society the roles of much of what is called in social science “conventional” or “alternative” are often reversed, with biomedical taking on the character of the alternative. (2000, p. 464)

Thus, Csordas and colleagues furthered our understanding of emic conceptualizations of health and the eccelectism and syncretization of Diné healing practices.

Place, Space, and Therapeutic Landscapes

Several scholars have explored the centrality of place in American Indian thought and experience (Basso, 1996; Carbaugh, 1999; Gone, 2008; Wendt & Gone, 2012; Wilson, 2003). Basso’s ethnographic work with Western Apache peoples helped to demonstrate how Apache culture, history, social structures, and wisdom are inextricably linked to place and, in fact, cannot be understood without recognizing this connection. Because Apache people see places as the connecting spaces between the human and spiritual realms, such places are sacred. In the early 1990s, scholars in the field of cultural geography began to explore the concept of therapeutic landscapes, which are places associated with or places in which the process of healing or treatment occurs (Gesler, 1992), or places that contribute to maintaining health and well-being (Williams, 1999).

Gone (2008) was one of the first scholars to specifically link these two strands of thought to theorize place and space as important concepts related to healing, wellness, and treatment among Indigenous peoples. One of Gone’s contributions was to highlight that many non-Western peoples view their relationships with the land as interpersonal rather than as relationships with material landforms. If we understand the land as sacred and as the embodiment of spiritual beings with whom AI/AN people have relations, we see more clearly the devastating mental health consequences of Euro-American colonialism and the displacement of many AI/AN peoples. In addition, the qualitatively different relationship many AI/AN people have with the land suggests that “culturally competent” approaches to healing and treatment must go beyond superficial attention to differing values and beliefs to more in-depth understandings of the cultural processes through which healing can occur and through which well-being can be maintained (Gone, 2008).

Opportunities to “give testimony to” processes of colonialization that disconnected AI/AN people from their histories, lands and cultures (Smith, 2012) and to reclaim and revitalize cultural knowledge about the land, traditions, and histories are important components of healing these losses and promoting well-being. As such, traditional AI/AN health practices, spirituality, and cultural continuity have been found to protect against many mental health problems, including suicidality, depression, PTSD, and substance abuse (see, for example Chandler, Lalonde, Sokol, & Hallett, 2003; Garroutte, Goldberg, Beals, Herrell, & Manson, 2003; Whitbeck, McMorris, Hoyt, Stubben, & LaFromboise, 2002; among others).

This article describes: (a) a community-based participatory research (CBPR) approach to understanding youth, parent, and elder perspectives on coping with stress, healing, and treatment, (b) findings related to the importance of the land and place, and (c) a community-university collaboration to translate these findings into meaningful change to improve the mental health and well-being within one Diné community through an intergenerational cultural and community mapping project. We inquired about health and healing from an intergenerational Diné perspective, setting biomedical modes and understandings of health and healing alongside both spiritual and religious modes of healing and everyday practices that promote coping and resiliency.

Method

Community-Based Participatory Research

We employed a CBPR approach in this study. We focused on understanding the sociopolitical context of mental health problems and treatments, and we strove for genuine collaboration among researchers and community members to identify and frame the goals of the research, research questions, methods, interventions, and data analyses. In addition, we aimed to recognize and build on the strengths of community members and researchers and to improve the lives of community members through applying what we learned to address community priorities. Finally, we emphasized understanding and promoting social justice (Minkler & Wallerstein, 2008). CBPR is particularly appropriate for research that addresses health disparities, and it is also especially important for research with AI/ANs because of the history of colonialism and exploitation and consequent lack of trust. In addition, CBPR emphasizes understanding and addressing oppression to build trust and genuine collaborative relationships.

Setting

The Navajo Nation is a sovereign nation spanning 27,425 square miles across three states (Arizona, New Mexico, and Utah). There are about 300,000 enrolled members, with about 174,000 living on Navajo Nation land. People living in the Navajo Nation face challenging conditions, including 51% unemployment and 37% living below the poverty line (Navajo Nation Division of Economic Development, 2010). The Navajo Nation is divided into 110 local government subdivisions called Chapters, which are located in five regional government subdivisions.

One of the Chapters, with a population of approximately 1,500, was the setting for the research we discuss in this article. The current study was preceded by more than 25 years of collaboration between the Chapter and the University of New Mexico (UNM) through a jointly run school-based health center and by more than eight years of collaboration between the first author and community members. After a particularly violent event in 2003, the community formed a community action team, and an elder asked to meet with the first author to share his vision about the impact of the last 500 years of colonialism and a vision for healing for the next 500 years.

Based on this meeting, the first author began to work with community members to develop a multilevel intervention centered on Diné cultural teachings that addressed past traumas and current stressors and built on existing strengths to foster youth, family and community protective factors (Goodkind, LaNoue, Lee, Freeland, & Freund, 2012a, 2012b). Following the initial implementation, the Community Advisory Council (CAC) suggested that we incorporate more traditional Diné perspectives on healing, historical trauma, and cultural practices into the intervention.

Our research team consisted of four women—a White community psychologist, whose role was principal investigator (first author), a Diné social worker who conducted most of the interviews (second author), a White cultural anthropologist who led the qualitative data analysis (third author), and a Hispanic/Acoma/Diné/White undergraduate student who was part of the data analysis team (fourth author). In response to the CAC, we therefore proposed additional research to understand community members’ perspectives on and experiences with healing, historical trauma, and coping with stress. This article reports on this qualitative, ethnographically informed research conducted in 2009 and subsequent application of these findings from 2010–2012 in collaborative efforts to promote the well-being of community youth, families, and elders. We obtained study approval from the local Tribal Chapter, the local School Board, the UNM Human Research Protections Office, and the Navajo Nation Human Research Review Board.

Participants

The first and second authors conducted 74 semistructured interviews with 14 youth, 15 parents/guardians, and eight elders who were grandparents in 12 community families. We selected the sample of youth with the aim of interviewing those who had sought mental or behavioral health services (n=7) and those who had not (n=7). The youth (six boys and eight girls) ranged in age from 12–17 years (M=13.8 years). We recruited the youth through the tribal behavioral health services, through the school-based health center, and during community events. We explained the focus of the study and asked interested youth to provide contact information.

The second author then visited each youth/family to explain the study. All youth agreed to participate and had at least one parent/caregiver agree to participate. To develop an intergenerational understanding of these issues, we also invited grandparents to participate. We interviewed 15 parents/legal guardians (10 mothers, two fathers, two aunts, and one uncle), ranging in age from 24–49 years (M=40.4 years). The eight grandparents we interviewed were all women and ranged in age from 54–90 years (M=68.5 years).

Interview Questions and Process

In consultation with our CAC, we devised guides for two separate interviews with each participant. Interviews were structured and comprised of open-ended questions. The second author conducted most of the interviews (n=54); the first author completed 13 interviews. Participants were interviewed in English or Diné, depending on their preference (all grandparents and two parents were interviewed in Diné). The first interview had two goals: (a) to gain an understanding of the demographic, familial, cultural, and geographic circumstances that shaped participants’ lives, and (b) to explore the ways they defined, understood, and experienced mental health and well-being. The second interview further explored participants’ mental health, challenges and stressors they faced in the past and present, their coping mechanisms, spiritual and religious healing practices, family life, and their interactions with health services systems and/or healers.

Although youth, parent/caregiver, and elder interviews included some common questions, for elders we added questions about daily life and the community in the past. We asked parents/caregivers questions about raising their children. To encourage youth engagement in the interviews, we asked them experiential and descriptive questions, asking them to walk us through a day at home during the weekday and on the weekends. The emphasis on experiential questions underscores a theoretical orientation through which we see culture as constituted in practice (Ortner, 2006) and culturally mediated concepts of well-being and health as reflected in the practices and activities of everyday life.

Data Analysis

The first four authors participated in the data analysis team. The third author and a professional transcription service transcribed the English language interviews. The second author and another bilingual Diné woman transcribed the Diné language interviews. The team checked interviews for accuracy and then imported them into NVivo 8, a qualitative data analysis software program.

We built the coding structure through an inductive and deductive process using a constructivist grounded theory approach (Charmaz, 2009). Charmaz’s approach reflects the view that co-construction of partial knowledge through interaction between socially involved researchers and participants is the goal of research. In this way, our goal was to identify themes that emerged from the data (such as Connection to Land), as well as purposefully including a priori codes that related specifically to our research questions (such as Coping; Health, Well-being). Thus, we combined inductive and deductive approaches to the data analysis.

The final coding structure consisted of 29 first-level codes representing the major themes in our data. All data analysis team members defined codes to ensure consistent coding, and then we coded all interviews using the same structure. We analyzed all major themes, looking for subthemes and patterns according to generation, gender, and other characteristics. We wrote memos analyzing the range of participant perspectives on each theme. Richards’s (2005) work guided our collaborative, writing-intensive analysis based on repeated reading, sorting, and consideration of patterns and negative exceptions in the data. These memos form the basis for the qualitative data analysis presented in this article. Then, we shared results with the CAC and incorporated feedback into our analysis.

Results

In this article, we present a brief overview of findings related to participants’ use of Western and traditional mental health services and healing/treatment modalities, as well as the ways in which they managed their stress and sought to achieve balance and well-being in their lives. From these data, the importance of land and place emerged. See Goodkind, Hess, Gorman, and Parker (2012) for more in-depth discussion of findings related to history, historical trauma, survival, coping, and resilience.

Youth Mental Health Service Use and Coping Strategies

Although half the youth had used Western behavioral health services, most did not mention these in their interviews. Youth who discussed these services usually talked about meeting with a mental health counselor for anger management, which they did not find to be helpful. For example, an adolescent girl said she was sent to anger management after a school suspension. The interviewer asked:

Interviewer (I): You went from September all the way until school ended in May?

Participant (P): Yeah, but it never helped me.

I: What could have been done to make it better for you?

P: Do something besides talking.

Similarly, another girl also emphasized the ways in which individual mandated counseling for anger management was not helpful:

Have you seen the movie like where this girl is put into a white room for no reason? Then she says, “Let me out. I didn’t do nothing.” … I feel like that because like we are in there for no reason. Like let’s say I was in a room, and locked up, and I was just hitting myself because I’m in there for no reason, for nothing, and I didn’t know what I did, and the more I bang on the door, the more they will think I am psycho. That was why when I went into that anger management, I was just all silent. I wanted to like yell at them, or something, but I thought they were going to think I was stupid and put me in a foster care or something.

This description of her experience clearly articulates some of the ways in which this “treatment” actually exacerbated her problems, including stifling her emotional expression, making her afraid, and increasing her anger. Based on our partnership with the mental health counselor at the school-based health center in the community and our ongoing participant observation for nine years in the community, we observed relevant patterns: (a) the most common response of youth in the community who were struggling with mental health or other problems was expressions of anger, and (b) anger management was the most frequently used “treatment” for community youth and was almost always mandated by school personnel.

The prevalence of youths’ anger in the community seemed to be in reaction to a lack of safety and stability and other multilevel problems, including lack of material, financial, emotional, and spiritual resources to support their growth and development. For example, at the time of the interview, the girl who described this experience with anger management was living part time with her grandmother and part time with her aunt. Her father was in prison and her mother had lost custody of her because of substance abuse problems. Given these circumstances, mandated anger management was not a helpful solution. However, later in the same interview, she contrasted her anger management experience with positive talk she experienced from other adults in her life:

If it’s [what someone says to her] nice, I just take it as a happy feeling. That preacher said I’m really outgoing, and I really listen, and have so many things to say, and I’m really an outgoing person … Then my teachers always say that I’m really smart, and I can do better than my mistakes … I just listen to them, and I think about it, and then I go along for awhile, and the day goes on like really good, and then when someone starts yelling, then I just go down.

This statement reflects a common theme among participants regarding the importance of positive talk in the maintenance of well-being (see Goodkind et al., 2012, for additional discussion). The only other youth who talked about participating in Western mental health counseling was an adolescent boy, who described his experiences with individual therapy as unhelpful. The negative therapeutic experiences described by these three youth are likely related to the fact that they were mandated to participate in individual therapy. Based on our experience in the community, we observed that youth were often quickly judged, labeled, and referred to therapy as a mechanism for discipline or control.

Most youth did not identify active coping strategies that involved formal help-seeking. However, many youth mentioned that talking with friends and family helped them cope with stress and made them feel better. Several youth described passive strategies such as sleeping or doing nothing when they felt sad or angry. Most youth said that they did not know much about traditional beliefs or practices; a few youth indicated they were not interested in learning them, but most said that they wanted to learn more about traditional beliefs and practices. Several youth also mentioned Christianity as a source of coping and healing.

Parent/Caregiver and Elder Mental Health Service Use and Coping Strategies

Almost half of the parents/caregivers indicated they were currently using or had utilized Western behavioral health services for substance abuse treatment. None of the parents/caregivers disclosed utilizing other Western mental health services, except for one who mentioned taking medication for depression. None of the elders reported using Western behavioral or mental health services, although they were aware of their presence in the community and that others used them. A grandmother explained:

Yes, there is the Behavioral Health Services in [community name]. They help us with these types of issues that we have in our community. They address issues like with the youth, and the problems they encounter. We also have [community action team], which we attend, where we are all able to voice ourselves and address these issues that are occurring within our community. [Community action team] works with Behavioral Health Services. The court is also within our community, which will make individuals do community services. All these things are in our community to make better lives or repair the lives of our people in this community. It is in these services, where individuals are spoken to and helped. If individuals do not understand or cannot get better, they are sent away to a place called “treatment.”

This elder was aware of multiple Western-based mental health and social services in the community. She seemed to appreciate their existence and had even participated in the community action team where she and others could share concerns and solutions. However, she had not used any formal mental health services offered by Behavioral Health Services and did not necessarily have a clear conceptualization of what these might be. Instead, this narrative reveals how this elder conceptualized Western services through a lens that viewed “place” as a key component of healing. As such, this elder seemed to conceive of treatment as a place where healing could occur rather than as a particular therapeutic process or modality.

About half of the elders and parents mentioned traditional belief systems and practices that helped them heal. They discussed traditional Diné ceremonies, chants, prayers, and blessings. For example, a mother explained how a Diné traditional ceremony helped her heal from a traumatic experience:

Participant (P): After the accident, I had a ceremony. And I think the ceremony worked for me. I felt like it helped me more. And the church, I don’t know, I didn’t feel good about it. Well, I’ll just put it this way. After the ceremony was done for me, I felt like, you know, take a deep breath and like phew, like that feeling. That’s how I felt. It’s hard to explain it….

Interviewer: Was it with a Navajo medicine man?

P: Yeah. I’d go in a church and everything. I’d feel like I was, like I still couldn’t breathe, or like I was still feeling like I was still choking, like I couldn’t take a deep breath. Or my lungs were filling up, and I couldn’t breathe. After the ceremony, it felt like I could breathe again, and I can feel it, and I knew it, so I think that helped me more than anything.

Many participants also talked about local plants and herbs that were important for healing and the prevention of disease. A mother described these practices:

My father used to gather mountain medicine. … I know he used to gather all sorts of herbs, I don’t know their names. He would utilize them in prayer, and to help a person to feel better. He used to try to teach us too. Sometimes he would make an herbal mixture and drink it himself, or he would give it to my mother when she would not feel good. With the herbal medicine he would feel better and revive himself or others. … I used to have a hard time believing that herbs could heal; and now I do believe. I remember once when I was sick, he had put together some herbs, and I drank it. Sure enough I was feeling better.

The primary coping mechanism parents named was prayer (discussed by 80% of parents/guardians). Although some participants emphasized the effectiveness of traditional ceremonies and prayers in contrast to Christian prayer (such as the mother described in the previous paragraph) or vice versa, most parents valued and used both traditional and Christian prayer. A mother described this syncretic approach:

When someone is not doing so well, or having a hard time, or is struggling, the first thing I think of is prayer. Getting the assistance of prayer, or having the person go to church, a person can utilize both to get through their struggle. On the other hand, the person could get help through traditional ceremonies. With this the person can move through and save themselves from their struggles. A person then moves forward balanced and living life in a good way again.

Connecting to Land and Place for Well-Being

In the course of the interviews, youth, parents/caregivers, and elders all expressed the importance of place and land for well-being and healing. For Diné people, “home” or the land in the deepest sense is the Navajo Nation: a place where ceremonies are conducted, where their umbilical cords and placentas are returned to the earth after their birth, where their families live, where they can go to rejuvenate and get away from hectic life of urban settings, where they can be immersed in their own culture, and where they can go for healing. Many Diné ceremonies, prayers, and blessings are conducted within the area marked by four sacred mountains, and families place great importance on this.

All Diné creation and emergence narratives are organized around oral teachings linked to sacred historical markers found throughout the land (Zolbrod, 1987). In this way, identities are associated with places, and thus, place is important in healing and returning to harmony or balance (for more on the importance of place for Diné people, see Benedek, 1993; Carmean, 2002; Kelley & Francis, 1994; Linford, 2000). However, given that youth and many parents did not believe they had much knowledge about traditional cultural teachings and practices, we did not necessarily anticipate that connection to the land and its importance for coping and well-being would be articulated by so many respondents. Thus, we were struck by the prominence of these themes. A girl explained:

Usually when I’m mad I’ll usually just go up to a hill and sit up there for a while. It’s nice and quiet and … it’s like a place you can think. … That’s the way it is. I’m kind of used to it, because when you go outside it’s peaceful.

Another youth, an adolescent boy, not only described how being outside helped him deal with stress, but also revealed his deep interest in and knowledge of narratives about the land around him:

Interviewer: What about you, how do you deal with it? When there’s something really—maybe your family’s going through some hard times … how do you deal with it?

Participant: I just hang around outside. … In Arizona when we were going to Marie’s house, we’re turning into a canyon, and it’s like two of them, and then you go down, and then a lot of trees make it look pretty. … Remember how the Navajo people wore dresses, and real turquoise, and then their hair was tied up like this, and they were carrying bags too? Then there’s a rock back there, and it’s really tall, and there’s those three girls, and they were walking and they’re bending over like this with a stick. Then they were telling us about that, and then saying that they walked through Window Rock, Arizona too. Then there’s a rock shaped like three girls walking towards that way—it’s pretty cool.

While conducting and analyzing interviews, we recognized that youth became more talkative when discussing the land. In many cases, youth described strong connections with the land and meaningful land-based practices to help them deal with challenges in their own lives.

Although it was not as frequent, several parents/caregivers also highlighted the importance of the land to them and their families. For example, one parent stated:

I’ve been coming back every now and then when I was smaller, spending time out here with my family, and she [his mother] was always telling me stuff like you should stay here and help me out with the goats and her livestock. I stayed for a while, a couple weeks and months on spring break, and I like the rocks and stuff out this way. I can walk around, take some hikes, other things like that, drive around and see different parts. That’s mainly what I like, and right now I wish she was around to be here and just for her to know that I’m back over here where she was born.

For the parent generation, the land seemed to symbolize an important aspect of reconnecting to families, community, culture, and history.

Elders frequently talked about the land, and similar to the youth, they were the most talkative and animated during these discussions. They shared narratives about the land that related to traditional teachings, and they emphasized the importance of the land for their well-being. For example, a grandmother, shared this narrative:

Well there are stories about the rock formations, which my father told us as children. He had said that the rock formation is the blood of the Yei Tsoh, one of the monsters slain by the Twin Warriors. It is in Grants where the Twin Warriors fought with Yei Tsoh, and they fell down to the ground to the earth. Yei Tsoh lay there wounded, and his blood came out of him there. The dark rock [lava rock] formations you see in Grants are the blood of Yei Tsoh. This is one of the stories he would tell us, and we would listen, scared, holding onto one another as children.

Another narrative shared by the same elder highlights the sacredness of the land, and ways in which this sacredness is violated by practices such as mining:

They say there used to be a large body of water to the north of that mountain, and they say long ago, this was where the deer would drink from. Not only was it a watering hole for the deer, people say that the rainbow used to take deer from there, from up above; I remember they used to say this mountain is sacred. … I know just recently people have been taking dirt, about the color of your shirt, it is very red. They are taking it from the side of this mountain [mining]. We were wondering what could happen since they are doing this to this mountain.

Elders not only talked about the importance of the land for their own well-being but also mentioned their grandchildren’s connection with the land. For example, a grandmother explained: “They [grandson and granddaughter] spend the night on the mesa [a hill with a flat top] on Sundays. … They like it up there. It is just beautiful looking from the edge and seeing all the lights. That's what they say.” However, some of the elders’ descriptions focused on the loss of land and their concerns about losing additional land. Another grandmother stated:

As far back as I can remember this [canyon] is where we have always lived, my grandmother and us. There also used to be a home back across in there. … So many of our family members used to live back there, and we have been slowly moving out from back there because we were told it was sold. So I think often I feel we will be told to move again, or our land will be sold again, leaving us to move further out.

Another elder explained that she felt that the loss of their land reflected badly on their community, revealing how the legacies of colonialism impacted the well-being of her community on multiple levels:

Often I try to voice myself to my community and relatives, saying, “What do you all think about what has happened to us here? What about this small piece of land which we live on, and what was taken from us? What do you all think of this?” I try to voice myself this way. I remember this is what I had said during those days when these issues were discussed. I had to voice myself because it did bother me, and it still bothers me to this day. I am especially wary of how others, outsiders, view our community, I often think maybe they refer to us as, “Those people who have no sense or knowledge.”

This elder discussed the loss of their land in the context of describing stressors she faced, highlighting the continued negative mental health impact of colonialism and dispossession.

In sum, the importance of the land for well-being, narratives about the land, and herbs that grew from the land were all salient themes in youth, parent/caregiver, and elder interviews about their mental health, well-being, and how they coped with stress. It is important to note that the land was significant to youth, even though they often had less connection or knowledge about Diné cultural traditions than their parents and grandparents. Thus, these findings confirmed the intergenerational importance of the land within this Diné community. In addition, these findings demonstrated some of the ways in which material and cultural losses that resulted from historical traumas and ongoing colonial power relations have directly impacted the mental health of AI/AN peoples. Moreover, by attending to these perspectives on the salience of the land for coping and well-being, by listening deeply to participants, and by engaging community members in a participatory process of interpreting these findings, we were able to collaboratively plan and implement ways in which to translate these findings into community action.

Translating Our Findings: Community Place Mapping Project

As the first four authors analyzed the qualitative data in 2010, we shared our preliminary interpretations with the CAC. The CAC was comprised of 10 elders, parents, and youth who had been meeting monthly since 2005 to manage and guide the studies we were conducting together. The findings regarding the land and place profoundly resonated with the CAC. Therefore, in addition to the culturally centered family intervention study we were implementing, the UNM and CAC research team decided to begin a project of identifying and mapping important places in and around the community and collecting and documenting historical and cultural narratives about these places.

Initially, the elders and the second author created a large map of the community and identified 52 places of significance. The CAC then prioritized 37 places to include in the mapping project. Next, the elders shared narratives about each place during CAC meetings. These narratives were digitally recorded, transcribed, and translated into English. After the narratives were complete, the second author worked with CAC members and additional youth who belonged to a community Youth Council to photograph and collect global positioning system (GPS) coordinates for the 37 locations during the summers of 2011 and 2012.

This intergenerational endeavor brought together youth and elders for extended periods of time, including 10 group meetings during which elders and youth planned and problem solved and several weeks of hiking, mapping, and an overnight camping experience. During the hikes, elders pointed out herbs and other native vegetation and shared their significance. Thus, the team decided to add 13 types of plant life (with pictures and narratives) to the mapping project. Once all narratives, photos, and GPS coordinates were collected, the team created a geographic information system (GIS) map and a 56-page booklet with the narratives and photos of all places and plants.

Our efforts to assess the effects of the mapping project included sustained participant observation throughout the two-year project, both during the implementation of the project and at community meetings where the map and booklet were presented and shared. We also conducted a focus group with 12 elders, parents, youth, and behavioral health services staff who participated in the project. The CAC presented the map and booklet to community leaders and members and they will remain in the community for future use. The mapping project was transformational in many ways.

Improved Intergenerational Communication and Understanding

Participation in the project led to improved intergenerational communication and understanding, which was a key problem identified by participants in the ethnographic interviews. In the words of one parent:

I saw some beautiful interaction between our elders and the students. I was thinking, okay, between the young and the elders, they’re gonna clash. They’re gonna lose interest. But it was just the opposite. Having the elders to go to the historical site to describe that this is an area that is sacred. They just had abundance of things to offer to the youth. How the youth just embraced that. They were curious. I just felt that, even the elders at times, I thought, “Oh my gosh, they’re just a little too old or they’re frail to be able to go to these sites.” But again, just observing them, it seems like it kind of revitalized them. They were really anxious to wanna educate their young ones. I just thought that was beautiful. That was just nice. Then to put it on paper like this is just, wow!

Another parent explained: “I see between [youth participant] and [elder participant] here, they became good buddies. [Youth participant] was very, it seemed like he took care of the elderlies. He took care of them. He communicated with them.” One of the elders commented:

I was really motivated to do this project, and motivated to finish it. I also liked our meetings we had with the youth. We were able to communicate to them, and I hope from this they learned something from us. I really like the youth. I like that we did this with them. I also liked how we supported and worked with one another.

A youth described what spending time with the elders meant to her: “I think for the elders to share, it was important so that we would remember what they went through growing up. … Bonding with the elders was the fun part. We don’t usually do that.”

Increased Knowledge of Diné Culture and History

Youth and parent participants in the project also increased their knowledge of Diné cultural teachings and community history, which was another concern identified in the initial interviews. For example, a community behavioral health services staff member observed:

I think this project really proved that we can put the youth and the elders together and work on projects to do something positive for the community. I know that anywhere I go, a lot of our Native people always stress that it’s time that we need to re-educate our youth. We’ve forgotten our culture. We’ve forgotten this. That’s why things are the way they are. We need to re-educate. I think it's possible, and this project has proven to us, that it does work.

Elders seemed to value their opportunity to help youth learn more about their community, history and culture:

Basically, working with the youth, I really appreciate the fact that we gave them the opportunity to learn. We gave them the opportunity to know what is in our community, what is here, so that when they become my age and they’ll be able to take care of our land, take care of what is here, preserve it.

I felt like I was able to share these places and guide this project as I know most of these sites. I told the group the site names, and after we were able to visit these places … I really enjoyed and liked this project. I am really thankful for being a part of this project and for the project itself. It really helped me to remember what life used to be like … So this project really meant a lot to me to share this.

Similarly, youth described many aspects of their culture and history that they learned:

I wasn’t familiar with the locations and some of the locations have meaning behind them. Usually I would just see them and it’s just a place, but now I learned that they have history and meaning.

With myself, some of my family members lived in their own location and I learned where they lived, how they grew up, what they did. … I learned where the locations are, the history behind them, and the plants. I didn’t know we had herbs and plants that grew here, that are medicine and vitamins. I didn’t know we had that until they [the elders] brought it up.

I also got to learn some Navajo writing—not just how words are pronounced but how they are spelled.

Acquisition of New Skills

Another important outcome of the mapping project was that youth participants acquired new skills that they can use in the future, including GPS and GIS mapping, photography, oral presentation, and leadership. For example, a community behavioral health services staff described how one of the youth was very interested in the GIS mapping:

I remember him asking, “Could this be a career, if somebody chose to do something like this? This is so cool, the instrument.” He was just really enthused about wanting to operate those, and how to graph certain things. He said, “Could this be a career?” We said, “Yes, it could be a career.”

Elders also noticed changes in the youth:

[Youth participant] did start up to be very shy … Then the more and more these research going, he participated in all of them. Now, he has taken the lead to be the leader. Even with our last meeting, he did talk about this document. He made some changes. He made some recommendations. … He matured in this, working with this project.

[Youth] were definitely more confident and wanting to do more things. … I noticed that they were wanting to get more involved in the community.

Healing Facilitated by the Land

Finally, participants in the project experienced the healing power of the land and the natural environment through the process of being together in these places and connecting more deeply with them and with each other. For example, a community behavioral health services staff member explained:

So if you think about [one of the places in the mapping project], this is a sacred place, as our elders used to say, “Where there is water which comes from the ground, this is a sacred place.” Our elders revered places such as this, and communicated positively about these places. It is sacred places where the people would provide offerings to the Holy People to give thanks. These places are sacred, they are holy. That is how we think as Diné people about our land. Our youth in this project were able to see, experience, and expose themselves to these sacred places, so I think they have become stronger spiritually because of this.

Given the centrality of spirituality in achieving positive mental health and well-being within traditional Diné beliefs, becoming “stronger spiritually” can be viewed as an essential component of mental health promotion and healing. Several elder and parent participants described the happiness and healing that they saw this project bring to the broader community:

I felt like this project and sharing this really brings out happiness, goodness, and healing in our people. It was great to see some people happy and in good spirits when we presented this at the [Chapter] meeting.

We presented at our chapter meeting. There was a lot of positive comments … The response from our people, they were smiling, they were laughing, they were happy for this project, and then when these places or narratives were mentioned, you could see their happiness in their faces, their laughter … Our chapter president is very pleased with it too.

Furthermore, many participants emphasized that this project exemplified an approach that would result in healing for the youth, such as this parent who said: “You know our children are choosing the wrong paths in life. … Healing will take place with projects such as these. … That is where I feel healing will happen for our people.” Youth also observed changes in themselves. As one youth described:

I think for them [youth] to see it [the different places they hiked to], they seem like they have a different outlook of [Community]—actually seeing it and what the elders said. I think it changed a lot of youth—just being there.

In sum, these statements highlight the multiple ways in which the mapping project was beneficial to the mental health and well-being of youth, parent, and elder community members. As evident in the themes, the mapping project was instrumental in facilitating healing of cultural losses and intergenerational rifts that resulted from cultural losses, as well as in promoting positive well-being.

Discussion

We demonstrate that AI/AN communities have traditional beliefs and approaches to well-being and healing that might not be adequately recognized or incorporated into mental health disorder prevention and treatment programs. These traditional strengths include not only the use of traditional practitioners and advisors and participation in ceremonies, but also maintaining positive well-being through everyday experiences with and knowledge about the natural environment. Traditional Diné healing practices often take the form of ceremonies performed by a medicine person and also include associated beliefs and practices that permeate everyday life. These include the use of herbal medicine, prayer or reverence, use of traditional teachings through oral narratives, sacred connectedness to the land, and following certain prescribed behaviors.

Consistent with traditional Diné teachings and practices that emphasize that Diné people gain their strength from the land and that the land teaches Diné people to survive, Diné youth, parents, and elders revealed that their connections to the land were a vital cultural strength on which to build efforts to promote mental health, well-being, and healing. The results of our study also support the importance of addressing AI/AN mental health by understanding cultural losses that occurred as a result of colonization and by engaging in cultural reclamation. At the same time, researchers and practitioners should question the primacy given to Western mental health prevention and treatment practices that are frequently and implicitly considered to be universal, legitimate, and better because they are based on the knowledge of the dominant group in the United States (Debebe, 2012; Waldram, 2004).

In addition, participants articulated their lived experience in one Diné community. For Diné people, one of the major collective traumas they experienced was the Long Walk (1864–1868). More than 8,000 Diné were forcibly removed from their homeland and incarcerated at Bosque Redondo in southeastern New Mexico (Denetdale, 2008). This uprooting of Diné people from their land, an experience shared by many Indigenous peoples, highlights the importance of revitalizing connections to the land as a process for mental health, well-being, and healing. In addition, conceptualizing a mental health intervention around a mapping project, such as the one described here, is clearly linked to efforts to decolonize mental health treatments on many levels.

From a Western perspective, mental health is frequently conceptualized as an individual attribute, with the range of mental health interventions typically encompassing treatments for individuals, such as medication or individual therapy. One contribution of critical Indigenous perspectives on mental health has been to highlight the root social and political causes of mental health problems within many Indigenous communities. These emphasize that when examining the high rates of mental health challenges and health problems experienced by AI/ANs, it is important to understand the colonial context from which these inequities have emerged. By understanding AI/AN mental health within a colonial context, it is clear that healing from historical trauma at the individual and community levels is necessary to achieve well-being.

Importance of Community-Based Participatory Research Processes for AI/AN Well-Being

Numerous researchers and practitioners have noted the importance of community-based approaches for conducting mental health research with and promoting the mental health of AI/AN communities (Duran & Duran, 1995; Gone, 2006; Goodkind et al., 2011). This study was a collaborative community and university effort to promote well-being and mental health and reduce violence exposure among AI youth and their families, from which emerged an unanticipated emphasis on the natural environment and an innovative intergenerational mapping project. Because of the flexibility of a CBPR process, we were able to move beyond recognizing the significance of the land for well-being to creating a way for youth, parents, and elders to spend time together in important places, connect more deeply with them, and share knowledge about them with each other.

Limitations and Future Directions

It is important to note the long-term nature of this study, which involved multiyear collaborative projects and used data collected from multiple youth, parents, and elders to guide the actions of the university and community research team. However, we did not follow specific youth, parents, or elders to determine the effects of the mapping project on particular aspects of their mental health and well-being (e.g., psychological distress, depression, suicidality) over time. Future studies should address this next step. Another limitation is that we did not conduct formal psychiatric interviews or collect information about participants’ mental health status as measured by Western categories of serious mental illnesses, more common mental disorders, and stress. However, based on the existing literature, we know that all of these are common among AI/AN communities, including within the community with which this research was conducted. In addition, given that half of the youth in our study had utilized formal behavioral health services, it is likely that they were experiencing mental health problems of concern.

Conclusion

Recent federal health care reform includes an explicit focus on prevention and treatment for AI/AN communities (U.S. Department of Health and Human Services, 2011). This provides the opportunity and responsibility to critically examine the range of prevention and treatment options available. We argue that broadening our conceptions of treatment to include places as well as processes is important for well-being. This is significant not only for healing and well-being that might result directly from revitalizing a connection to the land, but also because it foregrounds the importance of cultural reclamation to address the negative mental health impact of the legacy of colonialism.

In addition, this approach might be highly engaging and has the potential to involve youth, parents, and elders in working together to improve community health. We found that youth, parents, and elders were more interested and engaged in the mapping project than in any of the other aspects of our programs in this community (e.g., family strengthening intervention, cognitive-behavioral intervention), as demonstrated by participants’ reflections during interviews and focus groups and levels of participation. Furthermore, as participants described and we observed, the mapping project was of paramount interest and value to other community members, including community officials and leaders.

For many AI/ANs, formal traditional resources and healing practices are often scarce, but at the same time, Western models of care do not necessarily fit or meet their needs. Thus, it is critical to recognize the importance of listening to individual, family, and community experiences and building on everyday cultural values and strengths. Through such a process, we not only helped youth, parents, and elders experience healing and well-being through connecting with the land, but also facilitated positive intergenerational relationships and increased youths’ cultural knowledge, which are protective factors against mental health and substance abuse problems (Whitbeck, Chen, Hoyt, & Adams, 2004; Whitbeck et al., 2002). We suggest the importance of recognizing that culturally “competent,” effective approaches to healing and treatment might need to extend to more in-depth understandings of the cultural processes through which healing can occur and through which well-being can be maintained. In this case, we learned that there are many more “places” of treatment than we imagined.

Biographies

Jessica R. Goodkind, PhD, is an assistant professor in the Departments of Sociology and Psychiatry at the University of New Mexico in Albuquerque, New Mexico, USA.

Beverly Gorman, MCSW, is an associate scientist in the Department of Psychiatry at the University of New Mexico School of Medicine in Albuquerque, New Mexico, USA.

Julia Meredith Hess, PhD, is a research assistant professor in the Departments of Anthropology and Pediatrics at the University of New Mexico in Albuquerque, New Mexico, USA.

Danielle P. Parker, BA, is a research coordinator in the Department of Pediatrics at the University of New Mexico School of Medicine in Albuquerque, New Mexico, USA.

Richard L. Hough, PhD, is an Emeritus research professor in the Center for Rural and Community Behavioral Health, Department of Psychiatry at the University of New Mexico, Albuquerque, New Mexico, USA, and Emeritus professor of Sociology at San Diego State University, San Diego, California, USA.