Analysis of the néhiyawak narrative interviews consistently revealed four overarching themes that highlighted what positively impacted their mental health and well-being, and what they need to attain optimal mental health and well-being: (a) relationships; (b) spiritual beliefs and cultural practices; (c) tānisīsi wāpahtaman pimātisiwin (worldview); and (d) ēkwa ōhi kikwaya piko ka-ispayiki kīspin ka-nohtē-miyo-mahcihoyān (these are the things that need to happen if I want to be healthy). An elaboration of these themes in the words of the néhiyawak follows.
Relationships
The néhiyawak found that relationships met their emotional needs, increased their self-awareness, provided opportunities for personal growth, and gave them hope. The néhiyawak consistently described these relationships as improving their mental health and essential for optimal mental health and well-being. One very young lady described how the support she received from her friends, family, and coaches made a difference to her mental health and well-being. Being able to talk about her concerns with others gave her ideas and different perspectives on problem solving, “they tell me what they did at that time, so then I have an idea of how …I’d like to handle my situation.” One woman said helping others made a difference to her mental health and well-being. She had earned respect, felt needed, and enjoyed a sense of pride from helping others with their problems. She shared, “I help kids when they have problems…I give them a place to sleep and a place to eat… a lot of kids call me ‘mom’…it makes me feel proud; it makes me feel …wanted.”
One middle-aged woman spoke of both the negative and positive relationships in her life and her past experiences had impacted her mental health and increased her self-awareness. She shared how she had been abused while she was in foster care and when she was adopted her life drastically improved. Her foster mother’s “morals [and]…nagging…really had an impact on the way I think…mom’s always said, ‘life is tough, life is what you make it.’” When the néhiyawak were asked what gave them hope, what kept them going, their first response was generally related to their relationships. One middle-aged man spoke about his children giving him hope and keeping him going: “My kids give me hope. I don’t want my kids to see me as being a quitter or giving up.”
These relationships allowed them to express their feelings; provided acceptance and a sense of belonging, pride and respect; provided the opportunity to reflect on their past experiences, different perspectives, and new ideas; ending and beginning new relationships fostered personal growth and self-awareness; and finally, relationships provided them with hope, knowing that they can always turn to a family member or friends for support.
The significance of relationships positively impacting mental health and well-being is not a new concept. However, given the history of colonization and especially the residential school legacy, it is essential to understand the increased significance of relationships on contemporary Indigenous peoples’ mental health and well-being.
Spiritual beliefs and cultural practices
Throughout the interviews, the néhiyawak spoke numerous times about the importance of their spiritual beliefs and cultural practices in improving their mental health, and essential for attaining optimal mental health and well-being. Their spiritual beliefs and participation in their cultural activities may be likened to enculturation as described by Zimmerman et al. [
64]. They define
enculturation as “the extent to which individuals identify with their ethnic culture, feel a sense of pride in their cultural heritage, and participate in traditional cultural activities” (p. 296). Ross [
52] spoke about traditional ceremonies providing a culturally acceptable venue for Indigenous peoples to express their feelings. The néhiyawak said that their spirituality, praying, participating in cultural events such as a sweat, sundance, and pow wows improved their mental health and well-being.
One woman shared how her spirituality was making a positive difference to her mental health. She explained how spirituality had been integrated into her daily life and that to her was religion. She wondered how others cope without having spiritual connections and expressed empathy for those who attended the residential schools and were forbidden to practice their spirituality and culture:
My spirituality was integrated into my daily life. For example, if you go pick sweet grass, don’t pick in excess, only pick what you need, and make sure you put tobacco there for Mother Earth. That is religion to me; you’re connecting with your spirituality that way. The Creator is that close, intertwined in your life, that’s how I feel. I’m not religious. I see other young people whose parents went to residential school [and] when those parents came home, they didn’t go to church and they didn’t practice Indian culture. I often … wonder when they have hard times or when they struggle, how do they go forward to the next day, to the next year, without having that spiritual connection.
One male elder shared his healing journey involved exploring his identity as a Cree man:
Really, my mind was confused, my way of life was confused…in time I met an Elder and found out that I had to find my identity, who I really was as a Cree person. I needed to find out about my morals, my beliefs and my values as a Cree person. Which I did!
Colonization has disrupted Indigenous peoples’ spiritual beliefs and cultural practices [
8,
43,
52]. It was only in 1933 that Indigenous peoples in Canada were allowed to participate in their traditional cultural practices without legal repercussions [
44]. However, in recent decades, there has been a revival of Indigenous strength and determination across Canada driven by the restoration of traditional systems of beliefs and cultural practices, the recovery and reclamation of languages, the growth of First Nations’ sense of national identity, and the reconstruction and deconstruction of Aboriginal people’s history [
62]. Today more Indigenous peoples are participating and finding renewed strength and spiritual resolve from participating in cultural ceremonies [
11]. According to Kirmayer and Valaskakis [
34], the recovery of tradition may be healing both at individual and collective levels. They assert restoring linguistic, religious, and communal practices as fundamental acts of healing. In addition, cultural ceremonies provide “individuals, families, and communities structures within which to acknowledge and mourn common wounds. Group healing, within ceremonies, reduces isolation; alleviates guilt, shame, and anger; and enhances feelings of self worth” [
42].
Aboriginal cultures are rich with ceremonies designed to build strength, restore balance, and promote healing [
8]. The néhiyawak narratives demonstrated their perceived benefits from attending cultural ceremonies. They described how, by attending and participating in the cultural and festive ceremonies, a cleansing of their mind, body, and soul occurred; this enabled them to have a “clear mind” and provided focus in their lives. The recovery of traditional ceremonies and practices engage individuals, families, and communities in ways that can promote solidarity, social support, and collective transformation [
33].
Tānisīsi wāpahtaman pimātisiwin (worldview)
This Cree phrase, tānisīsi wāpahtaman pimātisiwin, when translated means worldview, how you see life, how you see the whole piece of life. The néhiyawak in this study described how their worldview was influenced by their past experiences, formal, and informal education. The néhiyawak spoke about three primary areas that affected their tānisīsi wāpahtaman pimātisiwin (worldview) that improved their mental health and well-being: (a) taking personal responsibility, (b) their attitude, and (c) wícihisowin. This Cree phrase, wícihisowin, means helping oneself.
A male Elder shared how taking personal responsibility to make the changes in his life, attending Alcoholics Anonymous (AA), dealing with his anger, addressing his low self-esteem, focusing on positive thoughts, and having therapists who believed in him contributed positively to his mental health and well-being. He voiced, “what helped me is to really work hard on my problems, to listen, to practice, and to make changes in my life. Not just talking about it, but to make that change!” He acknowledged that he “couldn’t drink, be with people that use, or be in high-risk places such as bars or parties.” In addition, he stated he had “to deal with my anger, my resentment toward people who had hurt me.”
The néhiyawak explained that their attitude made a difference to their mental health and well-being. They described appreciating every day, thinking positively, accepting things as they are—believing there will be a positive outcome, having mutual respect, helping others, and having hope to improve their mental health. One young woman asserted, “just living every day to the fullest!” improved her mental health and well-being. A female Elder stressed the importance of being positive all the time and not worrying about the gossip. She was adamant in her belief that people often create their own stressors as a result of their lifestyle choices. She asserted:
A lot of people create their problems, because their lives or stories catch up with them. So, it’s best to be honest with yourself… It doesn’t matter how difficult, or negative a story is, I [change] it to something positive. I don’t focus and concentrate on the negative because I know that’s what causes stress and for people to become depressed. It doesn’t matter what other people say or think about you. What really matters, is how you feel about yourself!
A middle-aged man improved his mental health and well-being by having a positive attitude, working hard to achieve goals, and engaging in daily self-reflection. In addition, he stressed the importance of abstinence from drugs and alcohol made a difference to his mental health. He said:
It’s the way I look at life…be positive. You have got to work hard at everything you do. Anything you want, work hard for it… I don’t wake up in the morning feeling negative. This was passed on to me by my grandfather, and my parents, be happy when you wake up every morning, somewhere along the way things might change, but at least start your day off right. In my house, I don’t allow anybody to be grumpy, or mad, in the morning, I just say, ‘not now, don’t do that now, it’s the morning, let’s get up happy.’ And you never give up, you never ever give up!… It is important to abstain from drugs and alcohol because it never was a part of our culture and it doesn’t fit in our culture. I’ve never done drugs of any kind, including pain killers.
McCormick [
39] found setting goals facilitated healing for the First Nations people of British Columbia, they felt more optimistic and empowered. Examples ranged from setting career goals to goals of improving one aspect of one’s life. Before setting goals many of his participants reported feeling depressed and powerless due to lack of options and direction. Hart [
20] explained that it is “through the taking of responsibility for their own personal healing and growth that individuals will be able to attain
mino-
pimatisiwin,” meaning “the good life” (p. 44). Mussell [
43] described healing to begin with a personal decision, deciding that it is time to find help and to take the necessary risks involved in healing; often beginning by talking and expressing the feelings they have kept inside. Interestingly, in the Cree language there is one word that describes taking responsibility for all aspects of one’s life,
manācihisowin. When translated, it means
a person’s responsibility to look after all aspects of their lives. This entails living a clean lifestyle, physically, emotionally and spiritually.
Wícihisowin was achieved by the néhiyawak participating in formal and informal educational opportunities. One man talked about taking the training to be a life skills coach improved his mental health and well-being. As a result of the training, he was reacting differently to his environment and had changed his lifestyle. He said, “For myself, it is having that ability to … notice things and react differently to situations. I’m a life skills coach; it helped me a lot personally to adjust myself and my lifestyle.”
One very young woman attributed her past experiences, environment, and her children as her inspiration to make changes and improve her mental health. She spoke about the difficulty of living in an area that was “surrounded by alcoholics.” When she was incarcerated she continued to be surrounded by negativity. Thus, these life experiences provided the impetus for her to change the direction of her life. She talked about the importance of the courses she completed while incarcerated. These courses helped her to understand and manage her emotions, addressed relationships, and parenting. She spoke with enthusiasm about graduating this year, making new friends, and celebrating two years of abstinence from marijuana. She articulated:
Just seeing everything around me! I live in the town site, and it’s nothing but alcoholics. I don’t want to live that way; I don’t want to end up living like that. My kids! I don’t want to smoke anymore. I want to watch them have kids and be there to support them. I actually just got out of jail, being in there and seeing all that negative stuff was like, ‘whoa.’ It really was an eye opener! I took a bunch of classes in jail that were very helpful. I took emotions management, relationship skills, and two parenting classes. The classes were all for self-help…my schooling, I’m doing my adult 12 this year. I actually quit smoking up for almost 2 years now. Yeah! I lost some friends, but obviously they weren’t friends. I made new friends. I’m not such a burnout [laughs] anymore.
Overall, the concepts described within tānisīsi wāpahtaman pimātisiwin (taking personal responsibility, attitude, and wícihisowin) correlate with eight of the 14 categories known to facilitate First Nations healing as described in McCormick’s study [
39]. McCormick found the following categories facilitated healing for the First Nations people of British Columbia: (a) exercise; (b) involvement in challenging activities; (c) expressing oneself; (d) setting goals; (e) helping others; (f) gaining an understanding of the problem; (g) learning from a role model; and, (h) establishing a connection with nature. The vast majority of the néhiyawak in this study were already engaged in these
healing activities as described by McCormick [
39].
Within this theme, tānisīsi wāpahtaman pimātisiwin, the néhiyawak voiced several concepts related to their worldviews, the lens through which they view the world. They described how taking personal responsibility, their attitude, and wícihisowin improved their mental health and well-being. Personal responsibility entailed practicing healthy communication patterns; making the required changes in their life; acknowledging, addressing, and dealing with their emotions and feelings; having healthy boundaries; and exercising choice. Having a positive attitude made a difference to their mental health and well-being. A positive attitude included: appreciating every day; thinking positive at all times; abstaining from drugs and alcohol; practicing acceptance and respect; helping others; having hope; and a belief in an afterlife. wícihisowin, “helping oneself,” was achieved by participation in both formal and informal educational opportunities.
Ēkwa ōhi kikwaya piko ka-ispayiki kīspin ka-nohtē-miyo-mahcihoyān (these are the things that need to happen if I want to be healthy)
The Cree phrase,
ēkwa ōhi kikwaya piko ka-
ispayiki kīspin ka-
nohtē-
miyo-
mahcihoyān, translates to
these are the things that need to happen if I want to be healthy. The one word in Cree,
miyo-
mahcihoyān, takes into account the physical, emotional, mental, and spiritual well-being of an individual. When the néhiyawak were asked what they needed to attain optimal mental health and well-being they emphatically reiterated the importance of their relationships, spiritual beliefs and cultural practices, and their tānisīsi wāpahtaman pimātisiwin; however, there was an increased emphasis on aspects related to their socio-economic status, elements described by both the medicine wheel [
43] and the determinants of health [
47].
Indigenous knowledge provides the philosophical foundation for the medicine wheel. Although the medicine wheel symbol has different meanings and expressions for different First Nations, some of the principles are universal [
1,
55]. Sevenson and Lafontaine [
55] affirmed “that everything is related to everything else, that things cannot be understood outside of their context and interactions, and that there are four aspects to the human condition-the physical, the emotional, the mental and the spiritual” (p. 190). Mussell [
43] asserted that an individual’s physical, emotional, mental, and spiritual needs must be met for the development of human potential and “are required for survival and personal growth” (p. 115).
However, several of the néhiyawak in this study expressed that they were content with their current state of mental health and well-being and did not need anything else to attain optimal mental health and well-being. One female Elder responded, “I consider myself strong, healthy, as possible. I’ve did the best that I can.” Another very young lady asserted, “Right now nothing… I just like the way it’s going right now, I just like it… I love it, you caught me at a time where I’m thriving.” One middle-aged man felt that he would be able to manage whatever challenges the future may hold:
I think I’m in that place where I have that ability to change with whatever comes good or bad; it’s up to me. I know a lot of times it hurts and at some point you have to stand up and say, ‘Ok, now I have to go on.’ I don’t need to see a shrink or anything. Well, at one point I thought of it, but would never do it. Really it is self-pity; it’s just self-pity that you come out of, I do anyway. I just laugh [he laughed] and say, ‘Ok big baby, life goes on.’
The remaining néhiyawak clearly articulated what they required to attain optimal mental health and well-being. They voiced physical and intellectual (mental) needs that correspond with the medicine wheel [
43] and the determinants of health [
47].
The néhiyawak physical needs
The vast majority of the néhiyawak spoke of physical needs as described by both the medicine wheel [
43] and/or by two determinants of health—(a) employment/working conditions, and (b) income and social status [
47]. The néhiyawak physical needs were related to securing employment; having a home, a safe environment to live in; being able to buy sufficient nutritious food; being able to manage their chronic health conditions; and exercising on a regular basis. They saw the meeting of these physical needs as necessary to attain optimal mental health and well-being.
Numerous néhiyawak mentioned that being employed made a difference to their mental health and well-being and employment was perceived as necessary to attain optimal mental health and well-being. They described employment as providing stimulation, giving them hope, providing income which increased their personal freedom, and providing structure for their lives. One young woman spoke about how having a job prevented boredom and, more importantly, provided her with stimulation: “working, just keeping busy all the time, not being bored.” Another young woman described how her approaching graduation and the anticipation of obtaining employment gave her hope and made a difference to her mental health and well-being. She said, “I hope to graduate from university soon… hope to get a good job.” Another woman articulated how she had worked most of her life, she enjoyed her job, and most importantly the income allowed her more personal freedom. She asserted, “I’ve worked most of my life. I just enjoy working, I get along with people. Keeps me busy, I don’t get bored and [with] the money… I can do more.”
The ability for the néhiyawak to meet their physical needs is related to their income, whether or not they have employment. Income determines an individual’s living conditions, such as safe housing or whether they will be able to buy sufficient healthy food [
47]. Health status improves at each step up the income and social hierarchy, and there is mounting evidence that higher socio-economic status is associated with better health. In fact, these two factors (income and social status) seem to be the most important determinants of health [
47,
49] from a Western perspective.
Another young woman improved her mental health and well-being by exercising regularly, she shared “[Being] active, exercising. I go to the track in the evenings.” In McCormick’s [
39] study of facilitating healing for First Nations people in British Columbia, he found exercise helped his participants to feel better about themselves because they were able to feel stronger and more capable. We have known for a long time about the benefits of exercise as a proactive way to enhance our physical condition and combat disease; now, exercise is recognized as an essential element in building and maintaining mental fitness [
6].
The néhiyawak intellectual/mental needs
According to the medicine wheel as described by Mussell [
43], the intellectual/mental needs encompass an individual’s ideas, concepts, thoughts, habits, and discipline; all the mental tools used to make sense of, and to cope with, life. Numerous néhiyawak in this study thought it was necessary to abstain from drugs and alcohol, and this was perceived as necessary for them to attain optimal mental health and well-being.
One middle-aged woman said that she didn’t want to die as a statistic related to alcohol abuse even though both her parents did and she feared her biological siblings would die in the same manner. In addition, she said that she would have to change her social circle of friends to include non-drinkers. She proclaimed:
I don’t want to die as a statistic from alcohol or from abuse. Both of my biological parents had passed away that way. Even to this day my biological sisters and my brother, I think that they’re going to die from alcohol abuse. I just don’t want to be like that.
According to the First Nations Regional Longitudinal Health Survey [
14], community wellness is dependent on some form of sobriety. Sinclair et al. [
56] identified mental health and addictions as the most significant health issues for many Métis and First Nations communities. Their study also noted these issues were related to the larger social determinants of health, particularly poverty, and lack of education and employment opportunities.
Several of the néhiyawak in this study identified the importance of continuing their education as being necessary for them to obtain optimal mental health and well-being. One very young man who was currently in grade 12 said, “School, just having a feeling of going there every day … something to do … nothing bugs me there.” Another very young man was emphatic that he and his spouse required careers in order for him to achieve optimal mental health and well-being. He declared, “we would both have to have a career… we need to have careers, not I want.”
Education and literacy is a determinant of health, and health status improves with an individual’s level of education [
47]. Education is closely connected to an individual’s socio-economic status, and effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. It also contributes to health and prosperity by equipping people with knowledge and skills for problem solving and helps provide a sense of control and mastery over life circumstances. Education increases opportunities for job and income security, and job satisfaction. It improves people’s ability to access and understand information about healthy lifestyles [
36,
47]. According to Statistics Canada [
59], Aboriginal adults consistently have lower graduation rates than other Canadians. When comparing the attainment of a university degree, only 9.8 % of Aboriginal people have a degree compared to 26.5 % of non-Aboriginal Canadians.
There are many factors that can influence one’s health, including one’s mental health. These factors are commonly known as the determinants of health [
23,
47]. It has become increasingly accepted that health is interdependent on a variety of factors [
41,
47,
48]. Raphael [
48] explained that the social determinants of health are the economic and social conditions that influence the health of individuals and communities. The economic and social conditions of a person’s life have “far greater influence on health and the incidence of illness than traditional biomedical and behavioural risk factors” (p. 2).
The second goal in
A Framework for a Mental Health Strategy for Canada [
41], acknowledged the need to attend to the complex interaction of economic, social, psychological, and biological or genetic factors that is known to determine mental health and mental illness across the lifespan. Within this goal there is reference to address adequate housing, and to reduce whenever possible those factors that increase the risk of developing mental health problems and illnesses, such as poverty, abuse, and social isolation [
41].
Irrefutably, there are unacceptable disparities between the economic and social conditions of Indigenous people and non-Indigenous people in Canada [
22,
58]. The four themes derived from this narrative inquiry correspond to six of the determinants of health: income and social status; social support networks; education and literacy; employment; personal health practices and coping skills; and culture [
47]. Socio-economic status has been cited as the most important determinant of health [
36,
48] and without dispute, this determinant was disrupted by colonization [
45,
62].
In a previous study [
18], the perceptions of health from a Plains Cree perspective were explored and findings supported the determinants of health as an appropriate framework to address the health needs of Indigenous peoples and as a framework for federal, provincial, and local policy makers to implement structural changes necessary to decrease the health disparities between the Indigenous peoples and the rest of Canada. Using a consistent framework, such as the determinants of health, is useful to provide a benchmark from which to evaluate existing disparities, initiate changes in existing policy and program implementation, and to measure and evaluate improvement.