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In my formative years, my dad and I went running every morning on the Navajo Nation, where I was born and raised. We would wake up at 5:00 a.m., pray to the east with our offering, and then run to the east. On those runs, my dad talked to me. He often said, “When you grow up and you leave the reservation, life is going to be really hard for you because you’re female and because you’re Diné.* We still live in a world that doesn’t understand you. As your father, it’s my job to prepare you to be strong. I’m building up your strength by teaching you discipline, by talking to you every morning, by telling you the challenges you’re going to go through. I’m not always going to be here on this earth with you, so I need to know that you’re strong and capable.”
My dad and I were really close, and when he passed away in the summer of 2023, I went through a very difficult time. In our culture, even in grief we try to find balance. While we know that tears and sadness are natural, our elders have taught us to be mindful that grieving can overtake us in a negative way. All the stress, the anxiety, the depression can impact us physically as well as mentally. I was really struggling to find that balance. I missed my dad so much. I was overwhelmed by grief, and I was having trouble keeping food down. I realized that I needed to have a comfort ceremony.
Our comfort ceremony is very communal. It starts at about 8:00 p.m. and ends at about 10:00 a.m. the next morning. As the grieving person, you sit up all night and your family and community come and pray for you, led by a medicine person. You might not even know everyone who comes to your ceremony, because sometimes they’re helping the medicine person or were invited by them. But nonetheless, you know that everyone there is praying for you and that you’re supported—and you make new relatives in the process because they sat with you all night, and they prayed with you all night. Maybe they’ve cried with you, and maybe they’ve laughed with you too. All of that brings a sense of healing that is tied to the community.
Now, when I reflect on my comfort ceremony, I feel good, like I’m really supported by my relatives. I know that with my father passing, I’m not in this alone. My dad used to come to these ceremonies with me. During my ceremony, hearing the men from my community sing the songs I heard my father and my maternal and paternal grandfathers sing my whole life, and pray the same prayers, brought me a lot of peace and comfort.
That support from my family and the larger community persisted long after the ceremony. That day, I felt like all of the stress and grief that had filled me, that my body was holding in, was lifted off of me. My body felt that sense of comfort too, and for the first time in a long time I was able to keep my food down.
Indigenous Approaches to Health and Healing
My maternal and paternal grandfathers were medicine men, traditional healers in our community, as were other grandparents and elders in my family. My earliest understanding of health and healing came from their practices and what they taught me. I understood that there wasn’t just one path to healing—there were multiple ceremonies to address different types of ailments, whether those ailments were mental, physical, or even social. When thinking about health and healing, many people focus only on the physical being, but there are many more layers. We are interconnected, not only between mind, body, and spirit but also with external elements like the environment and our social world.
Our cultural teachings incorporate all parts of ourselves in connection to the world around us. My early morning runs with my dad are a great example. We run because our cultural teachings tell us that the morning deities are waiting for us. If they see that we’re sleeping when the sun comes up, then they’ll think we must have everything we want in life and don’t want their blessing—so we get up and pray with our offering and run.
Early morning running also integrates self-discipline. As my dad would say, it’s really easy to sleep in every day, but we need that sense of self-discipline because it builds mental strength. That in turn builds physical strength because we’re getting exercise, and it builds spiritual strength because we wake up and we pray in accordance with how we’re taught by our elders. We have a connection to the land and to the sky, and we’re strengthening that connection as we strengthen ourselves.
Indigenous† communities have understood for centuries what Western medicine has only recently begun to approach with its focus on social determinants of health, which consider how external factors like income and geographical location impact well-being. This wasn’t a scientific term when I was growing up, but the understanding and practice have always been essential parts of my own traditional cultural healing lens. Health is much more than just a physical or biological or physiological construct; there are many more layers to what actually produces health and what outcomes equate to healing, and they’re all important.
When you go to a medicine person, you tell them what’s happening, just like going to a doctor, but they don’t only want to know about physical ailments like allergic reactions or stomach pain. What’s impacting you as a human? What are your concerns? Is it your family? Is it your job? The medicine person considers various factors that might be affecting you. High blood pressure can be related to stress because of work or a household problem, and a medicine person hears the whole story.
One of the medicine person’s primary goals is to restore balance. That might be related to physical health—like making sure that we are consuming added sugar or alcohol in moderation so that we aren’t harming our bodies—but it also applies to the rest of our lives and to our environments. If I harm living entities, that may put me out of balance in the ecosystem because the plants, the trees, the air, the animals, the insects, are all part of our balance—and being out of balance in that way can also affect our physical well-being. As Native people, our homeostasis is not just in the human body, but with everything that’s living.
Restoring Indigenous Health
Indigenous tribes in North America have suffered from long historical waves of disease, genocide, and forced assimilation that resulted in loss of languages and culture, relocation, and mass death.‡ The US government took more than 1.5 billion acres of land from Native nations between 1776 and 1887,1 squeezing them onto smaller and smaller reservations often more than 1,000 miles from their traditional lands and food sources, and took hundreds of thousands of children to boarding schools to be stripped of their culture.2 Traditional healing practices and ceremonies were made illegal, punishable by prison time or the withholding of food rations, until the passage of the American Indian Religious Freedom Act in 1978.3
One result is that Native health has suffered significantly. Compared to non-Hispanic white adults, Native Americans and Alaska Natives have lower life expectancy due to chronic disease/illness, geographic isolation, low income, poverty, discrimination in health services, disparate social conditions, language barriers, and cultural differences that make accessing quality healthcare a challenge.4 We have higher rates of heart disease, cancer, diabetes, obesity, stroke, unintentional injuries (accidents), substance use, liver disease, hepatitis, poor mental health, suicide, sudden infant death syndrome (SIDS), and teenage pregnancy.5 We are also disproportionately affected by infectious disease. The cumulative COVID-19 incidence rate among Native Americans and Alaska Natives was 3.5 times the rate among non-Hispanic white persons, with the Navajo Nation having the highest per-capita case rates in the nation.6
Native American and Alaska Native communities have shown remarkable resilience in combating the current and historical social and health challenges—but we still have a lot of work to do. Access to Native clinicians makes a big difference because they bring essential cultural knowledge and context with them. For example, in the Navajo Nation, 21 percent of our community members do not have electricity, and about one-third don’t have running water.7 The Native physicians I work with bring that knowledge into their practice, asking their patients questions beyond the scope of most physicians. “Do you have running water? Do you have electricity at home? If your medications need to be refrigerated and you don’t have electricity at home, what can you do about it? If you don’t have transportation, then how do you make your appointments? Do you have a family member who picks you up?” They see all the layers that might affect why a patient isn’t “compliant” with their medication or misses regular appointments. These are issues that all clinicians, not only Native clinicians, can consider. Oftentimes, it’s the patient who is getting scrutinized. “How come you’re not taking your medication? How come you’re not being compliant?” But the clinician may not be taking that extra step to figure out why.
Collectively, my colleagues and I are finding strategies to improve health and well-being by bringing together Indigenous holistic medicine practices with Western medicine. That’s why, after many years of researching interventions to improve Native health, I began offering integrative healthcare services through my nonprofit organization, United Natives. In our clinics, which focus on treating mental health and substance misuse issues, our teams of Native American clinicians and medicine people offer counseling and traditional Indigenous healing practices both in person and via telehealth/telemedicine. The results have shown the power of integrative care to restore Native health and well-being.
Valuing Indigenous Ways of Knowing
Some readers may find it uncomfortable to consider Native American health and healing practices in conjunction with Western medical practices. One consequence of the systematic erasure of Indigenous cultures in North America and throughout the world has been the devaluing of Indigenous ways of knowing.
In Indigenous communities, knowledge is typically shared through stories and demonstrations, is communicated orally, and is developed and held communally, with mastery proven by practical application. Knowledge is holistic, and while decisions are made by the family, the knowledge and authority of elders is especially valued. But throughout the United States, the predominant scientific and medical training teaches students to prioritize what is measurable and explainable within the physical world, which is compartmentalized and broken into disciplines rather than taken as a whole. Scientific knowledge is typically shared in decontextualized settings and measured with tests that often don’t include practical application. Significantly, Indigenous people have often been denied access to this type of knowledge and excluded from contributing to it.8
Indigenous ways of knowing are not often measurable by those scientific standards, but they are sophisticated and comprehensive ways of gathering information and understanding the world. If we are truly committed to providing culturally responsive care, addressing racial health disparities, and supporting health and well-being for all, we must respect the hard-earned knowledge and wisdom of others, even if it takes forms we are unaccustomed to.
Integrative Healthcare in Practice
My colleagues and I have chosen to concentrate on mental and behavioral health at our clinics because the lingering impacts of COVID-19 have really brought that need into focus.9 Many of the people we work with are dealing with heavy substance abuse. The two most common triggers we have observed are physical or sexual abuse from childhood or from loss of identity, by which I mean connection to their language, culture, spirituality, and community. For these people, one or more of those connections either has never been there or has been disrupted, and they have lost connection to themselves.
Reconnecting to Cultural Identity
Restoring those connections and pride in cultural identity is important because our communities suffer from a lot of shame associated with stereotypes about Native Americans and the discrimination we have faced. We weren’t legally allowed to practice our spirituality and our culture until 1978, so it’s very new for many of us. Many people were shunned for their faith or pushed toward Christianity.
There’s also the loss of language, which is directly connected to our culture, our spirituality, and our lineage. As a Diné person, my clans are highly important because they tell me my lineage. We have four clans: the mother’s, which is always your first clan; the father’s, which is your second clan; the maternal grandfather’s, your third clan; and then the paternal grandfather’s, your fourth clan. It’s all matrilineally derived. My first clan is my mother’s first clan, which was her mother’s first clan and her mother’s before her, all the way back. My four clans directly connect me to my ancestral lineage, which is a big part of my self-identity. Not only that, but through knowing my clans, I know who my family is. I was recently at a football game, waiting for food at a concession stand, and started talking to a Navajo man I had never met. I found out that his first clan is my first clan, so we’re kin. When I see him again, I won’t greet him by his first name—I’ll greet him formally as my brother. I’ve met thousands of other Navajo people I’m related to by our clans, and we’re automatically family in the same way.
Knowing who we are from a tribal context is powerfully associated with self-identity because community and family are very important to us. We meet new relatives as we move through the world, and we greet them as family along our life journey. When our patients come in and they don’t have that knowledge, whether it’s because they don’t know one of their parents or because that connection has been lost, they are missing a crucial connection to themselves and to the larger community. So when they come in, we try to reintegrate the cultural piece, and we focus on what pieces of themselves they already know and how to build on that part or rebuild it if it’s been broken.
Many of our patients say that when they come to us, they feel understood in a way that they did not feel in other programs that were not specifically for Native Americans. They may never have engaged in spiritual or cultural practices because their families were Christian or they were ashamed to practice who they were. They may not have been encouraged to learn their culture or their language. Many of them are connecting for the first time, and they are finding true, beneficial healing engagement and better self-understanding as they learn more about their culture.
Providing Integrative Services for the Whole Person
We offer clinical services, including individual, family, and group therapy, as well as referrals to Native physicians as needed. We have worked to integrate cultural aspects into our clinical work where it’s appropriate. For example, our group therapy sessions begin with smudging sage, sweetgrass, or cedar, a widely accepted Native practice that helps to set the tone. These are sacred herbs and plants to us, and the sweet smell helps to erase negative energy and bring comfort to our clients. It also elicits an automatic spiritual and cultural connection for them, which enhances their road to recovery. But we also try to be careful. We don’t want to make people feel like they have to engage in spiritual practices, especially if the practices are unfamiliar.
Once a month or bimonthly, we also make the services of a medicine person available for those who are interested. They talk to clients, telling stories and discussing how to apply them to their health and healing, offering a more overarching way of understanding themselves. They also offer individual prayers in person or by telehealth to complement the individual therapy sessions. Clients can participate in a group prayer or ceremony (like my comfort ceremony), or they may request individual prayers or ceremonies. We also understand that faith is a huge part of health and healing, and we encourage people to continue practicing any faiths they may already observe. We don’t want to discard Buddhism or Christianity, but we do want to give our clients the opportunity to practice Native American spirituality.
Our focus on treating and restoring balance to the whole person means that we also offer programming that helps people reconnect to their culture and their self-identity in other ways. In one cohort, we had several artists who were drawing Native-based pictures, and we started making a coloring book. To each page we then added in how to say numbers in different tribal languages. An activity like that is not necessarily spiritually or culturally based, but the element of language revitalization developed organically, and then we shifted the activities to focus on that.
We also offer education and community engagement opportunities that clients may not have had before. Many Native people do not know our own history because we were not taught it in K–12 public school systems. We have the sense that we are wrong for being who we are and that systems and institutions of the United States are not built to include us, but we don’t know why. So we teach clients about US policies and break down the historical contexts of colonization and the impacts of trauma resulting from those policies. When clients are armed with the knowledge that this is why our community experiences economic and health disparities, they can begin to ask, “How am I going to proceed as an individual, and how are we going to proceed as a community?”
We also bring in Native people who hold elected office or have become community leaders or doctors because we know it’s important for us to see that our people are smart and capable. Our clients also see our physicians, who are all Native American, and they see me, the owner of the organization. They know that I look like them, and I come from the reservation just like them. I’m “Dr. Lee,” but I can make rez jokes with them and talk to them in our language. Our clients are really enmeshed in this community where they’re highly supported and they can see and visualize Native Americans in a different way than they may have been able to do before. It’s not just the clinical piece or even the spiritual, traditional piece; we’re bringing the social and educational elements too.
The Integrative Difference
We’ve been able to see firsthand how this holistic, integrative practice can make a difference in our clients’ lives. One woman who was using fentanyl had been in and out of different rehabilitation programs for years, including ours. She would leave one program, go home, continue to do drugs, and then come back into a program when she decided that she was ready to move forward.
She’d had no exposure to Indigenous healing practices, but one day she asked if she could have a prayer done. She had always practiced the Christian faith, but she had grown curious about cultural forms of faith and healing. When she came out of the room after the medicine person finished the prayer, she was crying. She told me, “I’ve never felt so rejuvenated and focused on my own sobriety or felt that I was capable of doing it. It never clicked. I never thought that this could actually be a new part of my life, that I could be sober.” Before, she felt like she was just going through the motions of treatment, but she didn’t really believe she could change. Now, she did.
After that day, her attitude and her self-confidence transformed. It was easy to see in her daily group therapy—she talked more often and was more engaged in general. It was also reflected in her individual therapy sessions. It was like a mental switch had flipped for her: “Oh yeah, I can do it. I believe I can get sober, and I’m going to do it.”
It wasn’t just our program that had made the difference—this woman had been in our program before. But she had never worked with the medicine person. That’s the story for a lot of our clients. We bring all these elements together, and it’s synchronous, and the client finally gets it. Then they can move forward in their sobriety and in their health and healing.
We’ve had many people in our program who have completely changed their lives. Our clients come in with a lot of attitude because they’re trying to get sober and they’re dealing with powerful cravings. When they first come in, they don’t want to engage in group therapy or talk to anybody. They’re very closed off. But once we start to integrate them individually into the cultural, spiritual aspects, their whole attitude changes. They become more receptive. They become more compliant to our schedules. They become more involved in their own health and healing journey.
Really, we’re not healing them. They’re healing themselves, using the tools we have given them to bridge the gaps with traditional culture, with language, and with spiritual practices. They have a stronger self-identity, which leads to self-respect, self-efficacy, self-responsibility, and better decision-making. We see their emotional changes, their mental changes, and their desire. They want a healthy life, a sober life. Now, they believe that they can have it.
Crystal Lee, PhD, MPH, MLS, was born and raised on the Navajo Nation. Her tribal clans are Tachii’nii (Red Running into the Water), Tabaaha (Water’s Edge), Tsenjikini (Cliff Dwellers), and Kin I ichii’nii (Red House). She conducts infectious disease biomedical prevention research with a focus on Native American health and examines Indigenous health policies at tribal, tribal-state coordination, national, and international levels; she is also the founder and CEO of United Natives, a nonprofit that serves Indian Country.
*Instead of using the word Navajo, we renamed ourselves. As a nation, we now call ourselves Diné, which means “the people.” (return to article)
†Throughout the article, terms such as Indigenous, tribal, Native, and Native American and Alaska Native are used interchangeably. (return to article)
‡To learn more about how Euro-American colonization affected Native American cultures, food systems, and health, see “Traditional Food Knowledge Among Native Americans” in the Fall 2020 issue of AFT Health Care. (return to article)
Endnotes
1. R. Onion and C. Saunt, “Interactive Time-Lapse Map Shows How the U.S. Took More Than 1.5 Billion Acres from Native Americans,” Slate, June 17, 2014, slate.com/blogs/the_vault/2014/06/17/interactive_map_loss_of_indian_land.html.
2. V. Segrest and J. Hipp, “Traditional Food Knowledge Among Native Americans: Building Trust, Healing Trauma, and Restoring Health,” AFT Health Care 1, no. 1 (Fall 2020): 22–29, aft.org/hc/fall2020/segrest_hipp.
3. D. Zotigh, “Native Perspectives on the 40th Anniversary of the American Indian Religious Freedom Act,” Smithsonian Voices, November 30, 2018, smithsonianmag.com/blogs/national-museum-american-indian/2018/11/30/native-perspectives-american-indian-religious-freedom-act.
4. National Center for Chronic Disease Prevention and Health Promotion, “Healthy Tribes,” Centers for Disease Control and Prevention, cdc.gov/chronicdisease/resources/publications/factsheets/healthy-tribes.htm.
5. Office of Minority Health, “American Indian/Alaska Native Health,” US Department of Health and Human Services, minorityhealth.hhs.gov/american-indianalaska-native-health.
6. H. Wang, “Why the Navajo Nation Was Hit So Hard by Coronavirus: Understanding the Disproportionate Impact of the COVID-19 Pandemic,” Applied Geography 134 (September 2021): 102526, sciencedirect.com/science/article/pii/S0143622821001429.
7. M. Phillis, “Navajo Nation Wants US Government to Account for Tribe’s Water Needs,” azcentral, March 17, 2023, azcentral.com/story/news/local/arizona-water/2023/03/17/colorado-river-sparks-debate-between-navajo-nation-us-government/70021411007; and B. Newland, “Tribal Energy Development: The Future of Tribal Energy Development; Implementation of the Inflation Reduction Act and the Bipartisan Infrastructure Law,” Office of Congressional and Legislative Affairs, US Department of the Interior, March 29, 2023, doi.gov/ocl/tribal-energy-development#:~:text=Specifically%2C%2021%25%20of%20Navajo%20Nation,overall%20lives%20of%20Native%20Americans.
8. University Libraries, “Indigenous Research & Knowledges in North America: Indigenous Ways of Knowing,” University of Colorado Boulder, libguides.colorado.edu/c.php?g=1052968&p=7645909; and R. Datta, “Decolonizing Both Researcher and Research and Its Effectiveness in Indigenous Research,” Research Ethics 14, no. 2 (2018): 1–24, journals.sagepub.com/doi/10.1177/1747016117733296.
9. N. Panchal et al., “The Implications of COVID-19 for Mental Health and Substance Use,” KFF, March 20, 2023, kff.org/mental-health/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use.
[Illustrations by Christin Apodaca]