Perspectives on restoring health shared by Cree women, Alberta, Canada

Summary

The purpose of this study was to explore nehiyaw iskwêwak (Cree women’s) perceptions and beliefs about how to restore balance to health. Fifteen indigenous women from Northern Alberta, Canada, participated in a 3-day cultural retreat on beauty and art in British Columbia, Canada, in May 2015. At the end of the retreat, these women were invited to participate in a talking circle and asked, ‘What does restoring balance look like?’ A constructivist grounded theory approach was used to explore individual and collective perspectives on restoring health. Nehiyaw iskwêwak provided a vision of health using metaphors from the natural environment. Starting points and core characteristics of health were grounded in relationship with self, others, place and the land, suggesting interventions grounded in land-based pedagogy and focused on restoring relationship and secure attachment might be effective for this population. Nehiyaw iskwêwak also said interventions should start at the individual level; as the individual restores balance mentally, emotionally, physically and spiritually, a long-term ripple effect can be initiated through the generations and community when these women in turn support the strengthening and nurturing of relations (e.g. parents, siblings, friends, children, grandchildren) for the next seven generations.

INTRODUCTION

Sexual health is complex and involves physical, mental, emotional, spiritual and social well-being (Edwards and Coleman, 2004; World Health Organization, 2006). Threats to sexual health are insidious and ubiquitous, rooted in social conditioning, gender discrimination (Hayon, 2016), sexual discrimination, sexual abuse and violence, sexual coercion (Williams et al., 2013), abuse of power (Gesink et al., 2016), economic insecurity (Breiding et al., 2017), stigma (Hood and Friedman, 2011) and the limitation and restriction of sexual and reproductive rights, choice and freedom (Fortenberry, 2013). Human immunodeficiency virus (HIV), and other sexually transmitted infections (STIs), are one sign that sexual health is out of balance (Cedar Project et al., 2008; Gesink et al., 2016).

In 2009, we initiated a sexual health project to restore sexual health with a Cree community in Northern Alberta after concerning sexual health trends were observed by the health director of that community. In-depth interviews with community members suggested that HIV, and other STIs, were the physical manifestation of deeper physical, mental, emotional and spiritual trauma experienced through abuse of power in historic and current relationships (Gesink et al., 2016). Thus, there was a need to restore balance to health holistically before sexual health could be address specifically.

There are diverse ways of knowing about the world and how to interact with it and every individual and culture has their way of gaining this knowledge (Blackburn, 1999). The Canadian government’s aggressive assimilation policies—from the patriarchal Indian Act, which removed women’s powerful leadership roles within governance systems (Coates, 2008), to the forceful systemic removal of indigenous children over the age of 5 into Indian Residential Schools (The Truth and Reconciliation Commission of Canada, 2012; Mosby, 2013; Bombay et al., 2014)—invalidated, undermined and eroded indigenous knowledge for generations. Despite, these traumatic disruptions to the governance, kinship circles and knowledge exchange of Cree people (one of the largest First Nations in Canada), we believe that collectively, indigenous women hold invaluable knowledge about how to restore balance to health holistically and nurture the next seven generations of strong, healthy indigenous families. We use the word balance because in Cree worldview and language, health is being in balance and living a good life, in harmony with all our relations (wahkohtowin) (BearPaw Legal Education & Resource Centre, 2009). The purpose of this study was to explore nehiyaw iskwêwak (Cree women’s) perceptions and beliefs about restoring balance to health holistically, during a retreat on beauty. The purpose of the retreat was to remind nehiyaw iskwêwak about their own sacredness and power.

METHODS

Thirteen predominantly Cree women (10 Cree, 3 Métis) participated in a 3-day cultural retreat on beauty and art in the mountains of British Columbia, Canada, in May 2015. The primary intention of the retreat was to bring nehiyaw iskwêwak together to work with one another on reclaiming, creating and expressing a definition of beauty (sacredness and power). A secondary intention of the retreat was to host a talking circle on how to restore balance to health.

Women were recruited to participate in the retreat through snowball sampling via the professional and social networks of the two host artists using social media, email and word-of-mouth. The majority of women who participated were motivated by wanting to be part of the arts-based research project on beauty, and the chance to share and be part of a supportive network of indigenous women.

Talking circles are an indigenous method used to explore a topic (e.g. health) and co-create solutions (e.g. how to restore balance) in a safe and protected space where each individual’s thoughts, experiences, feelings and ideas are respected (Becker et al., 2006; Kovach, 2009; Rothe et al., 2009). Talking circles are like focus group discussions because they reveal social/group psychology. They are also like individual interviews because each individual in the circle takes a turn speaking. Each participant may choose to validate or build upon previous participant contributions; add unique experience, novel thoughts or insights; or pass and not speak. Participants will not explicitly correct or disagree with previous contributions, but may provide alternative perspectives to round out a discussion if it seems unbalanced or does not reflect their lived experience or understanding. This practice is culturally driven.

Our intention was shared with participants when the talking circle was opened. An elder then led a prayer and reminded participants of circle protocols, including practicing respect, nonjudgement, equality, confidentiality, speaking for oneself only and speaking only when holding the talking totem. Participants were then asked, ‘What does restoring balance look like?’ The rest of the circle was structured in terms of participant turn-taking.

Each participant voiced their perspective in turn through the circle process. Normally, after one complete pass around the circle, the facilitator will decide if a second round is needed to saturate the conversation. The facilitator, together with the participants, decided that all participants had equal opportunity to contribute their thoughts and that the conversation was saturated after one round. Accordingly, the facilitator closed the circle. The circle lasted 1 h.

The talking circle voice recording was transcribed verbatim and analyzed by both an insider, specifically, a community researcher trained and experienced in qualitative analysis, and an outsider, specifically, a university researcher from a large urban university in Toronto with 6-years of learning, experiencing and building relationships within Cree culture and conducting research with a Cree community in Alberta. The talking circle transcript was analyzed using a constructivist grounded theory approach (Glaser and Strauss, 1967; Charmaz, 2014). We took indigenous worldviews, values and priorities into consideration as we constructed the process to restore balance to health based on nehiyaw iskwêwak thoughts and recommendations. We used grounded theory because we were concerned with both summarizing what participants said literally and exploring the deeper meaning of what was communicated. The verbatim transcript was read and coded at the individual level, then compared across speakers to explore group level perspectives. Memoing was used to group codes into categories and concepts. Reflection facilitated the crystallization of codes and concepts into themes inductively. Themes were discussed with a third collaborator to increase rigor and validity of interpretations from an HIV and mental health perspective. This third collaborator was also an outsider—a white, male, psychiatrist, delivering mental health care in Toronto with 3 years of experience working with the same Cree community in Alberta. Connections between themes were made to reflect how nehiyaw iskwêwak conceptualize balanced health, and reviewed with all co-authors.

The ethics for this study were reviewed, approved and maintained by research ethics boards at University nuhelot’įne thaiyots’į nistameyimâkanak Blue Quills (formerly Blue Quills First Nations College) and the University of Toronto.

RESULTS

The 13 nehiyaw iskwêwak ranged from 17 to 61 years of age, with most in their 20s and 30s, three in their 40s, and one in her 60s. The literacy level ranged from illiterate to highly literate. The economic stability of the women ranged from unstable to precariously stable with one woman being homeless, several being students and most working part-time or on contract. Less than half of the women who participated experienced sexual violence or sexual abuse previously; however, the majority had experienced adversity including intergenerational trauma and poverty.

Nehiyaw iskwêwak talked about restoring health and being in balance using metaphors. A metaphor is a symbol or image used to represent a more abstract concept or vision, in this case, health. Metaphors were identified when symbolic language emerged in the transcript. We theorize that metaphors were used because health is an abstract and complex state of being and metaphors help make the intangible, more tangible and concrete. Most metaphors incorporated circles and lines. For example, one woman described:

I was thinking that circle, and I was thinking medicine wheel and you know, with all our, our directions and everything and how, a lot of times, everything gets slid over to one side cause we’re heavy on our, it may be physical, or you know, or mental, or emotional, spiritual, but it’s hard to be completely balanced in, all the time. I don’t know if that’s, I guess that’s restoring it, is maybe looking at that, looking at, where am I off balance, in those areas, in which direction am I leaning too much in? I was also thinking about harmony, you know, even though sometimes we’re off balance with harmony…

The circle is a symbol of strength and lines represent different paths or journeys in life in Cree world view. There are many Cree circle teachings and some describe relationships as circles that become weak if broken, especially by outside forces. One woman likened health to this kind of circle:

…to me, restoring balance would look like, everybody working together and not like, you know when somebody’s mad and, they don’t want to help that person, like it could be a big circle and, it’s made out of a bunch of little links and the second you take one link out, it’s not a circle anymore. So, if you take a person out and you don’t help the other person, then, it kinda just makes things go downhill…

The depiction of the circle comprising individuals (links) that maintain the integrity of the circle by maintaining relationship, and relationship being maintained by helping those in need reveals the interdependence of individual and community health. The interdependence of individual and community health, the importance of relationship and the importance of contribution emerged several times:

…the Cree word, I’m just trying to think, mâmawoh, is that the one? Working together to help each other? So, working together to help each other, has to happen, and, and then the community piece, for me, it’s being of service, we have a duty to give back, and you know, even if we’re the poorest of poor, we still have, we have a duty and responsibility to give back to our community and then society…

nehiyaw iskwêwak indicated that restoring balance to health included restoring connection with the land. One women stated explicitly, ‘So, for me personally, I’d say, balance begins with prayer and balance begins with taking lessons from the land and learning how to allow the land to teach you how to live your life.’ Another woman described connection to the land using the teaching of wahkohtowin, ‘I think restoring balance in yourself is just, respecting and loving mother earth and all those who dwell within her, and you’ll respect and restore balance.’ Land-based metaphors were also used to communicate the complexity of health over the life-course:

…listening to the sound of that stream out there, and to me that’s balance, that’s, trying to figure out how things flow and that’s learning how to move around the rocks and the obstacles. But, how do you apply those principles into your everyday life? And how do you know when to give, when to take, when to flow, and when to stand firm?

Some women used starting points when describing what restoring balance looks like. For instance, different women said restoring balance: ‘begins with acknowledging balance needs to be restored’, ‘begins with prayer’, ‘begins with taking lessons from the land’, and ‘begins with self, and once the self is in balance, one can help restore balance for family, friends, community’. All of these starting points referenced going inward, recognizing imbalance and disconnect and restoring health at the individual level before expanding outward to restore health at family/friend and community levels. One woman described this expansion process starting at the individual and being rooted in the individual knowing where they come from:

When I think about restoring balance, the holistic perspective, you know, it’s very complex, as you said, and I think about individual, I always think about 4 things, the individual, the family, the community, and then society in general; individually, I think, you know, that critical self-awareness, knowing where you come from, is fundamental, it’s fundamental to help our families heal.

The idea of healing oneself before helping others reflects the Cree teaching that we have to take care of ourselves before we can take care of others.

Some women used evaluation criteria to characterize balance in health. For instance:

When balance is restored, looks like, let me think, on a personal level, it’s being able to laugh again, ‘cause I know when I’ve been out of balance, and when I have those days when I’m able to laugh and like, laugh ‘til I cry, that’s when I feel things are back, things are getting back in balance. And, the same thing with, dynamics with people, balance will look like, just, as it was today, like where serendipitous stuff just falls into place and creativity flows and, it all just like is, feels right, like everything lines up beautifully cause you’re following your intuition.

Laughter, and being able to laugh, requires a healthy perspective and positive attitude, both of which are indicators of mental and emotional health. Being in the flow means being able to participate in life without the need for control, which is also an indicator of mental and emotional health, as well as having a sense of economic security. Following one’s intuition requires self-worth, self-confidence, self-efficacy and self-trust—including trusting one’s perceptions, interpretations and re/actions. Being connected to one’s intuition is particularly important for women disconnected from their intuition through abuse and trauma. These indicators that characterize health—laughter, being in the flow and following one’s intuition—can be used to develop measures for evaluating interventions and changes in nehiyaw iskwêwak health.

For some of women, health and restoring balance was grounded in spirituality, specifically, through intention, prayer and connection to a higher power; and continued to grow out of love, relationship and relational accountability:

Restoring balance, to me is, first recognizing it within yourself, and giving the power of intention out into the universe, of what it is your prayer is, and make your prayers clear, and with conviction. And if there’s conviction within your heart, I think that’s the first step because, you’re aligning yourself to be one with the universe and when you’re one with the universe, that’s when things start coming together, but also keeping your family close, and your loved ones, to me that’s restoring balance, because, they’re your backbone, they’re your rock, and restoring it, just never forgetting where you come from, your roots, staying grounded, and just taking time out for yourself, no matter how busy it gets, we’re never too busy to take time out for ourselves, we owe that to ourselves as women, as Cree women, and as human beings, because we, we need that because if we’re not loving ourselves, how are we going to love other people? And how are we going to love our community if we don’t share that love within ourself? And love is universal, so, that’s where, the good relationships will start, if it’s within yourself, and it’ll be a ripple effect, the healthier relationships will follow, in all different realms, people, world, society.

DISCUSSION

Cree, and many other First Nations communities, have a tradition of using the medicine wheel to talk about and conceptualize health (Dapice, 2006; Gesink et al., 2016). Nehiyaw iskwêwak worldview was grounded in the belief that we are not just physical, but also mental, emotional and spiritual beings—core aspects of the medicine wheel—and so used the medicine wheel to conceptualize health, both directly and indirectly. One of the under-recognized applications of the medicine wheel is to sexual health. Individuals and communities are healthiest sexually when the physical, mental, emotional and spiritual aspects of sex are in balance. One limitation of this study is that we did not ask nehiyaw iskwêwak to talk about sexual health specifically.

Nehiyaw iskwêwak provided metaphors, starting points and defining characteristics of being in balance that can be used to inform the vision (metaphors) for an intervention, identify the level and elements for intervention (starting points and characteristics of being in balance) and propose measures for evaluating an intervention (characteristics of being in balance) to restore balance to health.

Metaphors of health used by nehiyaw iskwêwak, for instance, health as a circle and health as a river, portrayed health as powerful and strong, yet also in precarious balance. This tension reflects the landscape of ubiquitous perceived and enacted threats to safety, security and health nehiyaw iskwêwak navigate on a daily basis (Spence et al., 2016). Nehiyaw iskwêwak recommended that health interventions include activities focused on the individual knowing where they come from. ‘Knowing where you come from’ is akin to having roots. Having roots is a powerful symbolic metaphor of a very real manifestation of stability.

The power of metaphors has been observed in studies understanding pain (Hearn et al., 2016). In our study, metaphors allowed women to share important, and sometimes painful, insights and personal experiences without making themselves, or others, vulnerable. Metaphors were used to pack the language and anonymize life experience and observations into generalized teachings that could resonate with any listener, without putting the speaker or listener in a vulnerable position or state because the focus was on the symbols and morals of the teaching rather than specific identifying details such as individuals, communities or events. In this way, metaphors were agents of safety, diffusing threats of lateral violence, labeling and passing judgment, while enriching and deepening the meaning of thoughts communicated (Blacksher et al., 2016).

Metaphors were also able to ‘mediate language, emotion and esthetic response’ the way other art forms can, such as music (Pannese et al., 2016). Metaphors helped the women follow Cree protocols that dictate teachings should be kind and gentle so no harm comes to another, and so the negative energy of past events was not brought forward into the present. The diverse roles and importance of metaphors suggested interventions involving nehiyaw iskwêwak could benefit from the use of metaphors to aid delivery and uptake.

The starting points and core characteristics of health presented could be used to co-create health interventions that resonate with nehiyaw iskwêwak and increase uptake, participation and impact. Nehiyaw iskwêwak suggested interventions start at the individual level and focus on healing the self before expanding outward to include healing family, friends and community. As the individual heals mentally, emotionally, physically and spiritually, they can begin to support the healing and nurturing of relatives (e.g. parents, siblings, friends, children, grandchildren) for the next seven generations. To our knowledge, interventions focusing on the individual first, then having the individual initiate a long-term ripple effect through the community have not been proposed before. Through this expanding process, healthy individuals with healthy support systems can raise healthy families and promote balance more distally, thereby contributing to stronger and healthier communities and generations.

Nehiyaw iskwêwak metaphors of health tended to relate back to the land and suggested that interventions with land-based teachings may be effective in the community. Land-based interventions are critical for addressing the colonial process of dispossession and disruption of the inherent spiritual, physical, emotional and mental connection to the land which has been directly linked to ill-health among indigenous peoples (Brown et al., 2012; Marsh et al., 2015; Women’s Earth Alliance, 2016). The importance of land-based practices for promoting health is slowly emerging in the published literature (MacDonald et al., 2013; King and Furgal, 2014; McCoy et al., 2016) and is a promising strategy for improving indigenous health and well-being.

Nehiyaw iskwêwak talked about ‘following your intuition’ as a marker of restored and rebalanced health. One oppression strategy of colonization was to disconnect nehiyaw iskwêwak from their intuition so they would second guess their own thoughts and decisions and thus would be easier to control. Intuition is heightened when mental, emotional, physical and spiritual knowing are attuned and in balance, which facilitates personal agency and empowerment, both of which were also ruptured during colonization and by the Indian Residential School system. Intuition is a vital component of decision-making (Lieberman, 2000; McCraty and Zayas, 2014; Pretz et al., 2014) and thus, impacts personal safety and protection from external mental, emotional, spiritual and physical threats and attack. Connecting with, and trusting one’s intuition, having personal agency and being empowered are important reminders to take a decolonizing and indigenizing approach to any intervention involving nehiyaw iskwêwak.

Economic security is a well-known social determinant of health for First Nations (Kolahdooz et al., 2015) and economic insecurity is associated with sexual exploitation, HIV transmission, violence and abuse (Baumeister and Vohs, 2004; Daoud et al., 2013; Negin et al., 2015). However, economic security was not raised as an area of health intervention despite the fact that most, if not all, of the women in our study were economically insecure. This omission suggests economic security and its relationship with health is under- or un-recognized by nehiyaw iskwêwak. The economic security of indigenous women needs support and intervention urgently, especially since it was identified as a risk factor for Missing or Murdered Indigenous Women by the RCMP (Royal Canadian Mounted Police, 2014, 2015).

All nehiyaw iskwêwak in this study had life experience with adversity, including trauma. At the same time, none of the women identified recovery from trauma as a core characteristic of health. Trauma could be part of the allostatic load carried by indigenous women (Lehavot et al., 2009) such that they no longer distinguish the burden of trauma, or it may be recognized, but not considered an indicator of health. Another possibility is that trauma was not discussed because the women were speaking in a circle from a strength-based place guided by ceremony and supporting and elevating each other through art and beauty, thus addressing trauma by focusing on personal strengths and strength reminders. Accordingly, while trauma recovery may be an important component of the healing journey; interventions and programs that provide protected time and space to focus on how to live a harmonious and stable life may be just as effective, or more effective, than interventions that address trauma recovery directly.

Knowing where one is from, following one’s intuition, having relational accountability, being able to use one’s voice to speak up for oneself, having a relationship with place, taking lessons from the land, and respecting and loving mother earth—these indicators of health are grounded in relationship, including relationship with self, others, place and the land. We developed a land-based sexual health intervention to address these connections and relationships with self, others, the health centre, the community, the land, the medicines, traditional teachings, ceremony and spirit in the form of a community garden. Elders explained that sexual health should not be addressed directly due to high levels of trauma and resistance within individuals, families and the community; but sexual health could be approached indirectly by the plants, which hold sexual health medicine and teachings, such as berries. There are other promising new interventions grounded in land-based pedagogies designed to build connections and restore relationship as well, such as the Haudenosaunee youth rites of passage program ‘Ohero: kon—Under the Husk’.

Attachment theory (Bowlby, 1988) posits that how an individual relates to themselves and others in close relationships is determined by their attachment style and attachment style is formed in early life (Wallin, 2007). Insecure attachment styles have been associated with social anxiety (Manning et al., 2017), post-traumatic stress disorder symptoms (especially anxious attachment style) (Woodhouse et al., 2015), sexual coercion (Karantzas et al., 2016), psychiatric symptomology and psychopathology (Fortuna and Roisman, 2008), pain (Forsythe et al., 2012) and suicide (Palitsky et al., 2013; Nagra et al., 2016). Conversely, secure attachment has been associated with psychological well-being and ‘an attitude of kindness and acceptance toward the self’ (Bowlby, 1988; Homan, 2016). Many of the recommendations made by nehiyaw iskwêwak could be interpreted as originating from a place of disrupted attachment. Restoring secure attachment may be the lynch-pin in restoring balance to health for nehiyaw iskwêwak (Smith et al., 2005). Restoring secure attachment is particularly relevant to Indigenous women because of the devastating impacts of colonization on Indigenous peoples disrupting relationships with self, family, community, culture and the land (Bar-On et al., 1998; Robertson, 2006; The Truth and Reconciliation Commission of Canada, 2012; Bombay et al., 2014; van Vugt et al., 2014).

ACKNOWLEDGEMENTS

We thank the women who shared their knowledge with us.

FUNDING

This research was supported by the Canadian Institutes of Health Research funding reference number 492948.

ETHICS APPROVAL

The ethics for this study were reviewed, approved and maintained by research ethics boards at University nuhelot’įne thaiyots’į nistameyimâkanak Blue Quills (formerly Blue Quills First Nations College) and the University of Toronto.

REFERENCES