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  • Sari Peltonen—Finland

Cultural competence transforming Indigenous mental health

Mental health and stigma are strongly interconnected in Indigenous communities. To drive change, we need culturally competent services, Indigenous people in leadership positions, and a more holistic understanding of mental health.



Mental health and stigma are interconnected in Indigenous communities, and culturally competent services are a key driver of change. Photo: Uvja


By the early 2000s, doctor and researcher Heidi Eriksen had participated in several international projects on suicide prevention. Her North American colleagues discussed the issues in their Indigenous communities, using words like ‘epidemic’ while searching for solutions to the crises.

 

Eriksen didn’t recognise the approach from her community of Sámi, the Sámi-speaking descendants of nomadic peoples who have inhabited the northern parts of Scandinavia for thousands of years. “Surely things aren’t quite that bad back home,” she thought.

 

After one such project, Eriksen sat down with a friend and started counting to establish comparative figures to the ones from North America. There are no official statistics based on ethnicity in Finland.

 

“We have a small community; we know everyone,” she says of Utsjoki, the northernmost municipality in Finland with a population of 1,200 people.

 

The resulting figures were a shock: the suicide rate in her community matched, if not exceeded, that among Indigenous communities in North America. Indeed, a 2017 study conducted by the Finnish government approximated the suicide rate among the Sámi population to be twice as high as among the general public.

 

“I understood we were facing a massive problem without even realising it ourselves,” Eriksen says.

 

Silence and survival of the Sámi people 

 

In Sámi communities, there is a deep-seated stigma attached to suicide and mental health problems, which are often linked. This stigma is closely entwined with shame and is deeply internalised. The problem has its roots in Finland’s 20th-century assimilation policies, particularly the boarding schools Sámi children were required to attend until the 1970s.

 

These schools, rife with violence and bullying, forced many children to hide their culture and language and integrate into the majority. This trauma spans generations and the effects can be felt to the current day, perpetuating a survival strategy of silence and concealment.

 

Cultural factors may contribute to the issue. According to Eriksen, self-sufficiency, or ‘ieš birget’, is an important positive value in the Sámi culture. “It refers to a child capable of catching a fish, making a fire, and surviving in nature,” she explains. “But it can turn into a toxic form of coping and survival without daring to ask for help, even when you should.”

 

Combined with structural racism, alcohol abuse, the perils of remote living, and limited healthcare services in Sámi languages, Eriksen describes the cultural burden as a “black cloud shadowing one’s life”. It is common to the entire community, but it becomes invisible and internalised. “Unfortunately, suicide is part of our normal,” Eriksen says.

 

Culturally competent care in Sámi languages

 

Eriksen now leads Uvja, a Sámi psychosocial support service that provides mental health services to the Sámi people, including counselling, crisis intervention, and psychotherapy, in accordance with Sámi culture and in the Sámi language.

 

“Without cultural competence, patients end up as cultural representatives, having to constantly explain themselves and their culture instead of simply receiving help.”

Its founding was one of the first actions of the Truth and Reconciliation Commission Concerning the Sámi People, which was established by the Finnish government in 2021 to address the historical treatment of the Sámi people.

 

According to Eriksen, providing mental health services in the Sámi languages is crucial. But she says cultural competence—understanding and respecting values, attitudes, and beliefs that differ across cultures—is equally important.

 

“When a reindeer herder [a traditional profession among the Sámi] says he is anxious because of the snow, it requires cultural awareness on the part of the therapist to understand why this might be a problem,” she says, explaining that reindeer struggle to find food and moving around becomes difficult when snow levels rise.

 

“Without cultural competence, patients end up as cultural representatives, having to constantly explain themselves and their culture instead of simply receiving help.”

 

The Uvja model, a small, agile unit that mostly operates remotely across a vast geographic area with modest resources, has proven effective. While it’s too early to report major results, Eriksen says the unit’s net promoter score, which measures user satisfaction, has been consistently very high.

 

She aims to establish Uvja as a permanent fixture in the Finnish healthcare system, providing equitable mental health services to Sámi-speaking Finns. “While I know that the quality of our service is high, what comes across repeatedly in the patient feedback is sincere gratitude for finally having a service like this,” Eriksen says.


Eriksen believes that the Uvja model could be adapted for similar situations or other vulnerable groups of people, where a relatively small investment can yield significant results.

 

Painful history drives fears of labelling and stigmatisation

 

Similar issues continue to play out in other Indigenous communities around the world, including those in Canada, where the legacy of dispossession is a key driver of stigma relating to mental health issues.

 

According to the First Nations point of view, mental wellness is more of an ongoing effort to maintain mental, physical, emotional, and spiritual balance in one’s life.

“The First Nations, Inuit, and Métis people have been removed from their homes and communities and placed in institutions that have caused serious harm. [These communities are] portrayed as having significant challenges, particularly with addiction, but are generally struggling with many types of social problems, including mental health issues,” says Dr Brenda M. Restoule from Dokis First Nation (Ojibwe) and the Eagle Clan. Restoule is CEO of the First Peoples Wellness Circle, an Indigenous-led national organisation dedicated to raising the profile of Indigenous mental wellness in Canada.

 

As a result, First Nations peoples may be reluctant to engage with the healthcare system for fear of harm or harmful labels, which can exacerbate mental health problems. Parents may not seek help for fear of their children being placed in the child welfare system, or fear of being labelled bad parents.

 

Restoule, too, underlines the importance of language and cultural competence as key components of the solution. “The term ‘mental health’ itself does not align with the worldview of the First Nations people in Canada,” she explains. While mental health is often viewed as something that one either has or does not have, according to the First Nations point of view, mental wellness is more of an ongoing effort to maintain mental, physical, emotional, and spiritual balance in one’s life. In Restoule’s native Ojibwe, for example, there isn’t a word for ‘mental health’. Instead, people use the concept of ‘good life’.

 

For the past decade, Restoule has seen a shift toward the First Nations, Inuit, and Métis communities themselves defining what mental wellness looks like for them. One outcome of this is the First Nations Wellness Continuum Framework, developed with input from over 600 voices from across Canada. More complex than Western mental health concepts, this framework emphasises community and broader social determinants of health, including land stewardship and environmental connection.

 

Restoule notes increasing efforts in designing, developing, and implementing mental health services that better align with the First Nations understanding of wellbeing. For example, there’s an increase in land-based activities—such as camps where people return to nature for day-long or week-long experiences—as an alternative to talk therapy. They participate in hunter-gatherer activities, pick medicinal plants, fish, and learn to build fires.

“Research demonstrates that the strong connection that people have to their cultures and communities contributes to a sense of pride, identity, and wellbeing, and that acts as a shield against stigma.”

 

“This fosters a connection to culture and language while also helping individuals recognise their place in the world. And it is rooted in reciprocity—caring for the environment as it cares for us,” Restoule says.

 

Psychiatrist and researcher Allison Crawford, who leads the Canadian Suicide Crisis Helpline and organises psychological services in the predominantly Inuit territory of Nunavut, says that at its most dangerous, internalised stigma discourages help-seeking behaviour, erodes self-worth, and undermines trust. She agrees that an effective first step is to build on the strengths from within.

 

“Research demonstrates that the strong connection that people have to their cultures and communities contributes to a sense of pride, identity, and wellbeing, and that acts as a shield against stigma,” Crawford says.

 

Indigenous people needed in leadership positions

 

In Australia, too, intergenerational trauma and structural inequalities are at the core of the issue of mental wellbeing among First Nations peoples, who have a shared history of the forcible removal of their children.


Photo: Uvja

“Being part of a minority already carries stigma, and mental health issues add a second layer of stigma, leading to the risk of double marginalisation.”

For many First Nations Australians, good mental health means having a sense of belonging, a strong cultural identity, positive interpersonal relationships, and the feeling that life has value and purpose. Disruptions to family and kinship connections, including intergenerational trauma, have been linked to increased suicide and suicidal behaviour. The rate of suicide for First Nations Australians is almost twice the rate of that for non-First Nations Australians.

 

Professor Nicola Reavley from the University of Melbourne led work on a 2021 report on mental health and stigma to inform the National Stigma and Discrimination Reduction Strategy. The report included consultations with Aboriginal and Torres Strait Islander people and lists several recommendations to ensure access to culturally competent health services.

 

Reavley stresses the importance of Indigenous leadership in reducing stigma toward people with mental illness. “You cannot address this issue without leadership by Aboriginal and Torres Strait Islander people, or those with lived experience of mental health challenges,” she says, explaining that First Nations communities promote inclusion and support for people with mental health issues alongside a strong sense of community, family, and kinship.  

 

Despite the huge challenges, what is emerging is slow but positive change. “Indigenous communities have a history of tens of thousands of years of living harmoniously with nature and a strong connection to the community. And while it was disturbed by colonialism, it is still there. Because of our current environmental problems, we are realising that when we’re out of harmony with nature, the damage is enormous,” Reavley says.

 

From Finland to Canada to Australia, Indigenous communities are separated by thousands of kilometres, yet they share common historical injustices and face a similarly complex present.

 

According to Eriksen, in her community in northern Finland, “a lot more work is required to reduce stigma and to introduce the idea that Sámi people too would dare to seek help for mental health problems.”


“Being part of a minority already carries stigma, and mental health issues add a second layer of stigma, leading to the risk of double marginalisation,” she says.

 

However, Indigenous-led clinics, camps, and other initiatives are gradually shifting the narrative. “This is a community-level issue, so community-based solutions are needed to fix it,” Eriksen says.

 

 


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