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Abstract

The approach to standardized services in Norwegian mental health care is tailored to the needs of the majority population, focusing on diagnoses and overshadows an approach that understands, values and emphasizes Sámi storytelling and everyday life. This study aims to contribute knowledge regarding the promotion of user involvement in mental health care from the perspectives of Sámi mental health care users. A narrative approach offers an opportunity to unravel an indigenous approach to mental health care and user involvement. People organize their storytelling according to culturally available narratives. This paper focuses on 9 Sámi men’s and women’s stories related to user involvement in mental health care services. Through a thematic analysis of personal stories, we emphasize how the participants make sense of their needs as patients in a culturally adapted mental health context and their experiences living in Sámi core areas. The following four themes are identified as prerequisites for user involvement in services: (1) the expectation of raising children to be independent, (2) the importance of accepting and recognizing the Sámi identity, (3) the need to live in close relations with nature and family, and 4) the right to be in the Sámi mode. Based on the results of our analysis, we find that user involvement among Sámi mental health care users is related to important Sámi values and norms within the culture and that treatment without these important values could adversely affect user involvement in mental health services.

Keywords

Sámi mental health care user involvement narrative analysis storytelling

Theoretical and empirical research concerning user involvement and mental distress in Sámi mental health contexts is limited. Research concerning Sámi mental health care should be underpinned by an understanding of Sámi cultural identity and practices and located within wider social contexts. The cultural context within mental health care in general poses challenges to mental health services for many reasons. We agree with Kirmayer (2012b) that culture influences the experiences, expression, courses and outcomes of mental health distress; help seeking; and responses to health promotion, prevention or treatment interventions. Mental health care takes a unique form in each society based on the cultural history, politics and economy. Mental distress and the tailored services offered reflect cultural knowledge and practices within the associated systems, which are embedded in larger social contexts that define health and well-being (Kirmayer, 2012b). Cultural worldviews, values, contexts and personhood influence how people articulate their identities through storytelling. Enduring negative situations is a central value of Sámi people because while waiting, the situation will improve (Minde and Nymo, 2016). This cultural way of managing daily life is not necessarily transferable to the biomedical understanding of mental health care.

Within the mental health context, both the culture of the patient and the “culture of medicine” coexist. Discussions related to culture should be sensitive to the risk of improper stereotypes (Good and Hannah, 2015). We agree with Good and Hannah (2015: 198) that culture-related discussions must also be sensitive to “the continuing significance of group-based discrimination and the myriad ways culture shapes clinical presentation, doctor-patient interactions, the illness experience, and the communication of symptoms”. We would also like to add user involvement to this context. Cultural communities and forms of cultural identity are variable, situational, dynamic, and embedded in struggles for power and control over resources (Good and Hannah, 2015). Cultures must be viewed as fluid, situated and negotiable intersubjective systems of meaning and practice relevant to specific social contexts (Kirmayer, 2012a). Culture refers to the shared knowledge, practices, values, and institutions that constitute the ways of life of communities or groups (Kirmayer, 2018).

Our study focuses on user involvement within the Sámi cultural context. User involvement in mental health care is a statutory right and means of ensuring that users’ needs for care and treatment are met. In recent years, Norwegian health and care services have experienced several changes within the framework of a deinstitutionalization policy, and there has been a major investment in the development of more user-oriented services (Klausen, 2017; Mathisen, 2017). Over the course of a year, approximately 16-22 percent of the adult population in Norway experiences a mental disorder. The most common mental disorders among adults are anxiety disorders, depression, and substance use disorder (Institute for Health Metrics and Evaluation, 2016). The health condition of the Sámi population appears to be similar to that of the general population, but studies indicate that the indigenous Sámi people experience more communication problems and are less satisfied with mental health services than the majority population (Dagsvold et al., 2020; Dyregrov et al., 2014; Møllersen et al., 2005; Sorlie and Nergard, 2005).

The structure of this article is as follows. First, we describe the Sámi. We present research concerning mental health care within Sámi contexts. We describe the data and methods with a focus on the narrative approach. Then, we introduce the participants. Next, we conduct a thematic narrative analysis inspired by Braun and Clarke (2006). We present excerpts from the participants’ stories before discussing the results.

The Sámi

The Sámi are indigenous people living in Norway, Sweden, Finland and the Kola Peninsula in Russia. The Sámi population is estimated to be approximately 100,000 people (Dagsvold et al., 2015). Most Sámi people live in Norway; the estimated Sámi population in Norway is approximately 55,000 (Statistics Norway, 2019), and approximately 25,000 members of this population speak a Sámi language (Ministry of Labor and Social Affairs,2000-2001). In this study, we concentrated on participants who self-identified as Northern, Southern or Lule Sámi.¹ Beginning in the mid-19th century, the Sámi people in Norway experienced a 100-150 year-long period of linguistic and cultural oppression and harsh assimilation policy (Minde, 2005) defined as the era of the “Norwegianization” of the Sámi people. This period of colonization led to the loss of the Sámi language, stigmatization and discrimination (Blix et al., 2013). The Norwegian Sámi policy has gradually shifted from the assimilation ideology, and currently, Sámi society is being revitalized (Dagsvold et al., 2016). According to Minde (2005), the purposeful, systematic and long-lasting assimilation policy distinguishes Norway from other states. This policy exposed Sámi to forced assimilation, discrimination and prejudice from the Norwegian society, including its mental health system (Turi et al., 2009). For many, the historical legacy of the policy of ignorance is still morally cumbersome and politically inflamed (Minde, 2005). For example, users of mental health services who have been exposed to the Norwegianization policy may have limited confidence in the Norwegian authorities. Many Sámi are still in a decolonization process (Nergård, 2011). Thus, the mechanisms of colonization and colonial power live in people (Mikkelsen, 2013). However, the collective identity narrative based on cultural traits, such as language, traditional clothing, traditional music, handicrafts and reindeer herding, has enabled individuals to develop their own identity narratives within an indigenous context.

Research concerning mental health care within Sámi contexts

Circumpolar indigenous people generally have greater health challenges than the majority population (Willox et al., 2015). However, research concerning user involvement in mental health care in indigenous contexts is lacking. A culturally relevant definition of mental illness or disease is missing in the circumpolar context (Willox et al., 2015). The life expectancy and mortality patterns of the Sami are similar to those of the majority population (Sjolander, 2011). Bongo’s (2012) qualitative study concerning Sámi understandings of health and illness revealed that the Sámi approach health and illness in silent and indirect ways. The standards for caring for oneself are strong. Care is provided by the nearest family members and relatives without the need for healthcare. Speaking openly about diseases is considered inappropriate, and diagnostic terms are rejected as judgmental. Nymo’s (2011) study concerning the everyday lives and health of older Sámi in Norway showed that interaction within stable collectives, such as families and neighborhood communities, provided security and opportunities to combine traditions and innovation. Møllersen et al. (2005) showed that therapists prescribed more sessions and more socially focused interventions in psychiatric treatment when patients were Sámi. The data were suggested to indicate ethnic differences in treatment planning and treatment goals (Brustad et al., 2009). Minde and Nymo (2016: 84) underlined that the most important motivator that could redefine a Sámi’s dignity [when being ill] was receiving care from family and close relatives, but the home and cultural landscape were also perceived as important.

The current situation of Sámi people in Norway is complicated; some Sámi areas have strong and ethnic support and a high density of Sámi, different languages have equal status and several Sámi institutions reside there. In other regions, the Sámi are a minority, and there is less support of their culture. Prejudice and conflicts regarding land rights and Sámi language are a part of everyday life (Turi et al., 2009). A study by Stoor et al. (2019) showed that Sámi understand suicide among Sámi people as related to historical and ongoing oppression, negative treatment of Sámi by other Sámi, shortage of culturally adapted mental health care, issues within Sámi networks and traditional cultural values. Related to this complex context, Sámi patients within the Norwegian mental health system require a different approach to mental distress (Minde, 2005).

Data and methods

Interviews with 9 users and 9 health professionals from mental health services within the context of the Sámi core area were conducted in this study, but only the interviews with the mental health service users are presented in this paper. This study was approved by the Norwegian Center for Research Data in 2018. The participants were recruited through the Sámi Norwegian National Advisory Unit on Mental Health and Substance Abuse (SANKS²). SANKS has the national responsibility for the development and delivery of services in mental health and addiction for the Sámi people in Norway. The main goals of the SANKS is to ensure equitable services and good accessibility for all groups of Sámi users, strengthen user involvement at all levels, provide a center for education, increase activity in research and development, and strengthen mental health care and addiction treatment for the Sámi people (Heatta, 2016).

The data were collected in Northern and Southern Sapmi throughout a period over a year, and the interviews were performed by authors 1 and 2. Both Sørly and Mathisen are Northern Norwegian, female, mental health researchers who has worked in the field for several years.

It was difficult to recruit participants for the study, and the project depended on “door openers” from local communities and people who worked at SANKS to contact participants. Conducting fieldwork became an important part of these interview studies. The fieldwork included spending time in Northern and Southern Sapmi and getting to know local people and local customs.

Information letters were distributed to the participants, and individuals who were interested in participating signed letters of consent. Most users spoke a Sámi language and were from reindeer herding families. All participants spoke Norwegian or Swedish. One participant was learning Sámi language, and her family had left the reindeer herding life. Only participants who had experiences with culturally adapted Sámi mental health services were included in the study. The participants could bring a companion to the interviews if they wanted and were asked what language they wanted to use during the interview. All interviews were conducted in Norwegian/Swedish according to the wishes of the participants. A thematic interview guide was used. The main topics were related to user involvement and the participants’ own experiences with treatment. Most interviews were approximately 60 minutes. The interviews were digitally recorded, and the sound files were transcribed verbatim. The stories presented in this paper have been transformed into coherent narratives based on the interviews. This process involved constructing comprehensive, condensed narratives. Comments or questions from the interviewer were omitted to improve the coherence of the narratives.

The participants

Two men and seven women participated in the study. The participants were aged between 20 and 75 years. Five participants worked in reindeer herding. One participant was a student, two participants were unemployed, and one participant was retired. The participants represented the Northern Sámi, Lule Sámi and Southern Sámi. The participants were given pseudonyms to protect their identity. The main types of mental distress these participants struggled with were substance abuse and/or mood disorders (depression and bipolar diagnosis).

Narrative approach and thematic analysis

This study employed a narrative approach. Storytelling is an important meaning-making activity for indigenous people (Allen et al., 2014; Chance, 1990). Stories offer local meanings and often provide symbolic parameters for appropriate situational behavior, which is shaped by community structures along with prevailing cultural scripts associated with characteristics, such as gender, age, and ethnicity (Allen et al., 2014). Stories are produced, distributed, and circulated in society (Gubrium, 2005; Klausen et al., 2017). Understanding how the stories we tell relate to social contexts requires an understanding of what those contexts do with words. The social consequences of stories must be understood in relation to what is at stake in the everyday storytelling context (Gubrium, 2005; Klausen et al., 2017 ). Contexts are of great importance in storytelling. Consistent with Ahmed and Rogers (2017), our epistemological approach to narrative analysis focuses on the significance and influence of context and, hence, the idea that knowledge can be understood as temporally, culturally and spatially specific.

Thematic analysis is suited to a wide range of qualitative data (Riessman, 2008); we aimed to focus on what was said and what remained unspoken rather than how the words were spoken. Using a thematic analysis, we performed an experience-oriented inquiry. We started with a single interview at a time, isolating and ordering the episodes into many different themes (Klausen et al., 2016). After completing this process with all interviews, we sharpened our focus and attempted to identify common themes across all interviews; episodes were chosen to illustrate the range and variation of certain patterns. We did not attempt to fit the data into a pre-existing coding frame or analytical preconceptions, and the analysis was driven by the data. The personal stories of our participants and their experiences provided the basis for determining the themes. In the following section, we present excerpts, followed by interpretations, theoretical formulations, and references to prior theory. In the specific stories, it was useful to read and compare the stories to each other and search for common topics and how they were expressed or what was left unsaid. The totality and parts belong together; the context and narratives are woven into each other and cannot be separated. Thus, all stories are contextualized narratives. Each story contains complex meaning.

Findings

The participants experienced culturally adapted treatment as decisive for user involvement within mental health services. Four themes were derived from the analyses, which were performed with the intention to provide rich descriptions of the breadth and complexity of participant experiences of being Sámi men and women in need of mental health services. The following themes are identified as prerequisites contributing to user involvement within the Sámi context: (1) the expectation of raising children to be independent, (2) the importance of accepting and recognizing the Sámi identity, (3) the need to live in close relations with nature and family, and 4) the right to be in the Sámi mode.

Theme 1: The expectation of raising children to be independent

Important Sámi values and norms within the culture are applied in the traditional way of raising children. Several participants underlined that the primary aim of Sámi child rearing is to prepare children for life and develop independent individuals who can survive in a given environment. Self-esteem is important. A broad network of ‘significant others’ around the child ensures the transfer of values and norms and prepares the child for adult life. Within the community, there is a dynamical psychological understanding that each child is different and undergoes an individual development process. Parents must show children patience, positive expectations and trust.

The advantage of indirect ways of raising children is the avoidance of confrontations among the involved parties. The focus is on an experience-based learning process. Sunna, a Sámi woman and reindeer herder who struggled with depression, was asked about her thoughts of her children’s futures. Did she expect her children to take over the reindeer husbandry work?

Sunna

Hm – So, that choice, they must – they must make it themselves. I can’t make it for them. But, I can give them the prerequisites. And, it [the prerequisite] is that you get to participate in this; so, that one … Yes, may be a part of it, as well. So, it is that you are with [us] – when we do reindeer herding, when we have slaughtering [of the animals] –That is the way that you get it into it. And then, of course, THEY must make their choice. I can’t do that. But, I can give them the prerequisites to know that they are part of some things.

Sara and Ole-Per were a married couple in their forties. They had four children, who all participated in the family’s reindeer herding. They wanted to be interviewed together at the kitchen table in their home. Ole-Per had been diagnosed with depression, and the couple attended family therapy. Sara served dried reindeer meat and coffee while we spoke. They were asked about how they raised their children.

Sara says:
“…the rules [for Sámi children] are a little fluid. They are somehow more … – if the situation allows it. So … why should one set rules about everything? It’s more that we want them to behave towards others.
Ole – Per continues:
Yes, and for example, calf marking, you know- then, you work at night. And, you sleep in the day. And then –
Sara interrupts:
We go to bed with the kids and get up with the kids. There is no such thing that … They are enough – you follow one like that – yes, a completely different circadian rhythm then.
Her husband says:
And – the same in the summer, right. Why should they lie down when … we have things to do…in the evening. … it doesn’t matter – when they go to bed. Yes, and then, they get to learn how to work with tools … which may not – as many others may think is a bit scary then … But, they get it now - they must go… mark reindeer calves and work with a knife and learn … marking and maybe cut [themselves] a little and –
Sara continues:
Cut a little, yes. It’s important to cut [oneself] because then, they get respect for – The knife, yes.
In a culture that emphasize self‐reliance, autonomy, and self‐sufficiency, the goal is to produce children whose behavior is internally controlled (Javo et al., 2004). Children should rely on themselves for internal direction rather than on rules for external direction. This presumes that children can decide how to act and possess the individual initiative to act on these decisions (Javo et al., 2004). Consistent with Javo et al. (2004: 76), we found that Sámi families have a “more stringent attitude towards their child’s outbursts of aggression or jealousy” and that their use of indirect methods of control indicate that in‐group harmony is important.

Theme 2: The importance of accepting and recognizing the Sámi identity

The Sámi identity was a central topic for all participants in our study. The participants underlined the complexity related to the recognition of an indigenous identity; the social recognition and collective acceptance of identity were treated as both values and norms. The participants asserted that one must simultaneously accept her/his identity and be recognized by her/his surroundings and the community as Sámi. The participants also explained that feelings are communicated through the regulation of emotions. During the interview, Ole-Per and his wife Sara described identity as a complex matter as follows:

Ole-Per

A Sámi identity is not a simple thing … Our identity has been challenged in so many ways … . We have all had some challenges in one or another setting … She [his wife] grew up as a Norwegian to-yes; [he asked his wife] How old were you? 12-13? And, when you turned 12, your father took back his Sámi identity. And [turns to the interviewer], she had to remodel her whole identity too. It is very much to handle…

Sara, Ole-Per’s wife, continued

And, it was so strange because when you grew up … in such a Norwegian [environment]… All – yes, a Norwegian childhood, you can say, everyone was Norwegian, and nobody knew about the Sámi … so, it was like something you miss all the time. Because it was something they didn’t understand. I don’t know – I don’t know what it was. If it was just … One or the other was because … when we – you had no community. You lacked that community. And, there was none – there was no one who understood anything. So, it felt different all the time in a way. And, you can’t put it into words. So, you had a longing all the time. And then, when you said you were Sámi, of course, you were harassed – yes, and then, you were different – and there was no – [pause] yes, everything was different all the time. Yes. So, I am very happy that my father took it – took it back again then [the Sámi identity].

The Sámi identity was not only Sara’s project. The need for acceptance was also two- sided; the traditional Sámi community is a society of small, tightly knit social entities that depend on mutual responsibilities and contributions among its members for survival (Javo et al., 2004).

Arja

The following excerpt describes a situation in which an individual’s Sámi identity was recognized by the local community, but some of the majority community³ questioned her Sámi identity. A psychiatrist asked Risten, Arja’s sister, about her experiences as a Sámi struggling with mental distress. It is difficult to guess the story the psychiatrist expected, but what he expected was certainly not the answer he received from Risten. As a Norwegian, the psychiatrist showed himself as a person who wanted to hear his patient’s story, which, in the Norwegian context, would most likely have been greatly appreciated by the patient. Risten did not refuse to tell her story, but her response suggests a difficult life; pain is addressed with “black” or morbid humor as follows:

Arja

I remember once she [her sister, Risten] told us [the family], yes, there was a psychiatrist who came to talk to Risten, and the conversation had been short. I asked her, “What did he ask you, and what did you answer?” The psychiatrist had asked Risten, “How has it been? How is it to be you here in the village where you are?”. And, as a person living in Sapmi, Risten replied as a Sámi, and the psychiatrist probably didn’t understand Sapmi; Risten replied, “If had you lived my life, you would have died a long time ago” (laughter). You know, there are quite common answers to such questions in Sapmi. All the way, complementary answers, and everyone knows, everyone understands what she thinks, but the psychiatrist didn’t realize it (laughter). It was the only conversation she had with a psychiatrist.

We interpret this type of humor as nárrideapmi, cf. Balto (2005). Nárrideapmi is an indirect form of communication that has several functions in Sapmi. First, nárrideapmi helps master social interactions and become aware of feelings. Feelings can be addressed through humor and in a joyful manner through nárrideapmi. Nárrideapmi is a way of controlling difficult feelings, such as anger, emotional outbursts, sensitivity, aggression and shame (Balto, 2005: 95). Through this “safeguarding of emotions” (Balto, 2005: 95), one does not expose her/his inner thoughts to strangers or outsiders. When Risten was asked by a Norwegian psychiatrist about her feelings, she could control the situation through nárrideapmi.

Theme 3: The need to live in close relations with nature and family

The participants spoke of the importance of collective strength in indigenous communities. They explained such collective strength as Sámi communities having tight social structures with close networks that provide resources and network members who assist with problem solving and support in times of special need. For instance, the Sámi model of child rearing is impossible without an extended network of adults around children who all participate in the rearing. There is a close connection between relatives and the neighborhood. Networks are traditional establishments that offer care, security and contact.

Ritva, a widow in her mid-40s, had lived in a southern town in the country for a long time. She lived alone with her son after her husband committed suicide many years ago. Her son began to abuse alcohol and substances, and she decided that they had to move back home.⁴ Her son was immediately involved in the reindeer herding by their relatives:

That was what was so good; when we arrived, it was not a dead period in the reindeer herding year; something was happening; so, he [her son] was able to join immediately – we were in the village for a week – with my brother. And, he [her son] started with this daily, and he was pressured a little, “You MUST get up at 5 am; it is not possible to sleep until 11–12 in the day. You MUST get up at 5 o’clock because then we drive. [It is] 30 degrees below zero, but we must go out”. It was VERY GOOD; it was, YES. He has been following reindeer herding this year since then. Yes, NOT a whole year yet. But, it will be soon.

In the interview, Ole-Per reflected upon relations with nature as a central Sámi value as follows:
Just to be able to manage outside in nature and treat it in a good way. To understand how everything relates to each other – that’s important no matter what you do. There has been enough people who do not understand nature, and look at what the world is becoming. I think you need an understanding of nature. We belong to nature. […] Sámi values are very sustainable. I want to bring this further [to the next generation].
We consider these excerpts to underline the importance of securing a network around children allowing the knowledge of Sámi values and norms to be transferred to the next generation. The network can act as a form of control for children, while other limits are imposed by the surrounding landscape, climate, working conditions, and geographical contexts (Balto, 2005). Thus, ecological knowledge of sustainability is of great importance to the current values and norms within Sámi core areas. In the epistemological universe in which humans and nature belong to the same world, health is closely related to nature. When Ritva’s son had problems, his relatives shared the belief that it would be good for him to participate in reindeer herding.

Theme 4: The right to be in the Sámi mode

Several participants spoke about the “Sámi mode” as the opposite of “the Norwegian mode”. We consider a mode to refer to habits or ways of working and how people operate within their different functions. The Norwegian mode within the mental health context was described as efficient, oriented towards diagnosis, and in conflict with Sámi core values. In contrast, the participants defined the “Sámi mode” as being in balance with nature, performing physical work and addressing one’s problems. While speaking to each other, Sámi people usually perform another task simultaneously; conversation occurs while engaging in another activity. The participants explained that the value of being independent is important, but Norwegian health service providers expect Sámi patients to abandon some of their core values. Arja, a Finnish Sámi lady in her late 70 s, spoke about Risten, her sister, who had lived alone for many years. Risten was diagnosed with bipolar disorder, and during the last years of her life, she needed help in her home. Arja was asked whether the professionals who assisted her sister spoke Sámi.

Arja, in her late 70 s, stated the following:
Only Norwegian …. Risten understood quite well, but the talking and, especially when, when I saw the last few years, when they [the home care service providers] came in the morning and the evening, it took a long time before Risten somehow, how to say it, could put the language on, but then, they had gone. Even before, she talked very little to them. They often talked so much; they asked Risten, “How are you”, “Yes, you’re fine” (laughter) before Risten managed to say anything. Or that Risten had, Risten failed to, it took some time before she went into the Norwegian mode. Then, they had already gone. Of course, we realized that they can’t wait for Risten to get into the Norwegian mode. But, we were so lucky that where Risten lived, a Finnish lady lived there who was married to a man from X, and they were Risten’s neighbors. So, I asked her, Minna, the next-door lady, if she could visit Risten every day if she had time, and she did it. She was with Risten daily and spoke Finnish to her, and Risten somehow changed a lot. She began to trust more people and became happy, but not so much that she could open the door. She was behind closed doors. But, Minna had her own key so she could come in.
Arja described how her sister held on to her Sámi values and was unable “to put on” the expected mode before the health professionals had left her home. She was not ready for their way of communicating or helping, and it took time before she could “warm up” and interact. However, the woman from next door let herself into Risten’s home and helped Risten with practicalities.

Ole-Per described the “Sámi mode” in another way as follows:

Interviewer: It takes a while to get into the Sámi mode.
Ole-Per: Yes. I have some experience with it in another way too since I work as an archeologist during the summer here – in the dryland season – and we – when you do interviews, if one should get information, to put it that way, that is to say – in the Sámi areas. You have some informants you are going to talk with – I have noticed that I have one great advantage, like if there is a Norwegian there, who is putting [information] into a system… to registrar Sámi cultural heritage, you know – he does not get the same trust. And, he doesn’t – he doesn’t understand the codes of talking in – [the Sámi mode] – right. Because first, you must talk about the weather and wind, and then, you have to talk about the snow that fell last year. And then, you must eat together, and…. check, check, check on all the points there [points in the air] – (laughter) AFTERWARDS, you get lots of information. And, that’s the thing – [mental health care] is a bit like that – when I sit as a patient …we must have that thing there, right.
Sjolander (2011) emphasized that several specific health problems among Sámi are related to reindeer herding. Most problems are related to marginalization, poor knowledge of reindeer husbandry, and knowledge about the Sámi culture in the majority population. Consistent with Sjolander (2011: 9), we agree that “the most sustainable measure to improve health among reindeer- herding Sámi would be to improve the conditions of the reindeer husbandry and the Sámi culture”. We find that the most important element in this work is to respect the Sámi people’s right to be in their mode. Reindeer husbandry requires flexibility and arising issues must take the time they demand. If the reindeers need you first, your appointment with the health professionals must wait. When the time is right, you can talk to your doctor.

Reliability and validity

Questions concerning the reliability and validity of a research project should be assessed from within the perspective and traditions that frame the research (Blix et al., 2013; Riessman, 2008). In this project, we have adopted an epistemological approach that focuses on the significance and influence of context in storytelling. Meaning is co-constructed, and the stories presented give the reader both an impression and a glance into the experiences of the service users who were interviewed (Klausen, 2017). The project was framed in an understanding of the consequences of a still ongoing colonialization process towards Sámi reindeer herders in Norway and the impact of such oppression on mental health care within Sámi regions.

Discussion: Communicating mental health in an indigenous context

This paper aims to contribute knowledge regarding the promotion of user involvement in mental health care from the perspectives of Sámi mental health care users. The participants’ stories are interwoven in accordance with Sámi values and norms. These values and norms are related to what mental health service users consider prerequisites for the ability to engage in their treatment together with health professionals. The professionals must have knowledge regarding the Sámi communities’ expectations related to child rearing and must accept and recognize the users’ ethnicity. Furthermore, professionals must know the users’ need to live in close relations with nature and family and must acknowledge the individual right to be in the Sámi mode. These prerequisites belong in a dimension between individualistic – collectivistic values in the Sámi cultural identity (Javo et al., 2004). While child rearing is connected to individualistic autonomy, the Sámi identity and the relation to nature and family are related to collectivistic strength. Being in the Sámi mode can be understood as an individualistic autonomous act. The cultural competence needed contains knowledge related to expectations, acceptance/recognition, expressing needs and exercising one’s rights.

Cultural identity is rooted in systems of knowledge, collective trauma and evolving contexts (Matheson et al., 2018). Culture is both social and individual; an individual may turn to her/his roots as a source of resilience in processes, such as meaning making, storytelling, social support seeking and the mobilization of collective action, or alternatively, an individual may reject her/his indigenous identity due to shame, resentment or anxiety (Matheson et al., 2018). As exemplified in the stories told by our participants, indigenous peoples’ health is connected to the ongoing and lingering impacts of colonization (Allen et al., 2014; Gracey and King, 2009; King et al., 2009). Experiences related to colonization include historical and contemporary examples of marginalization, exclusion, cultural suppression and forced assimilation. These experiences might lead to complications in navigating between indigenous and dominant cultural expectations and relating to factors both within and beyond the individual, and making sense of these relations in the local context (Allen et al., 2014) and the context of mental health treatment can be challenging. As presented in the Sámi mental health users’ stories, we can see how they emphasize empowerment by presenting their cultural identity as a knowledge starting point for user involvement. Health professionals need knowledge regarding the cultural Sámi identity and its complexity related to individualistic and collectivistic dimensions. One way to improve the mental health condition of reindeer- herding Sámi is to establish more health care centers, such as the SANKS, as integrated parts of reindeer husbandry. Otherwise, user involvement in these mental health service users will be forced into the frame of the still ongoing colonialization process.

Footnotes

Acknowledgments

We wish to acknowledge the contribution of the participants. We would also like to thank the reviewers, as well as the editor, for good comments on previous versions of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Sami Parliament (HS 003/18) and Sámi Norwegian National Advisory Unit on Mental Health and Substance Abuse (S- 07 2018).

ORCID iD

Rita Sørly

Notes

References

Ahmed

Rogers

(2017) Polly’s story: Using structural narrative analysis to understand a trans migration journey. Qualitative Social Work: Research and Practice 16(2): 224–239.

Allen

Hopper

Wexler

, et al. (2014) Mapping resilience pathways of indigenous youth in five circumpolar communities. Transcultural Psychiatry 51(5): 601–631.

Balto

(2005) Traditional Sámi child rearing in transition: Shaping a new pedagogical platform. Alternative: An International Journal of Indigenous Peoples 1(1): 85–105.

Blix

Hamran

Normann

(2013) Struggles of being and becoming: A dialogical narrative analysis of the life stories of Sami elderly. Journal of Aging Studies 27(3): 264–275.

Bongo

(2012) Samer snakker ikke om helse og sykdom. Sámisk forståelseshorisont og kommunikasjon om helse og sykdom. En kvalitativ undersøkelse i sámisk kultur [Sámi does not talk about health and illness. Sámi understanding horizon and communication about health and illness. A qualitative study in sámi culture]. PhD Thesis, The Arctic University of Norway, Tromsø, Norway.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Brustad

Pettersen

Melhus

, et al. (2009) Mortality patterns in geographical areas with a high vs. low Sami population density in Arctic Norway. Scandinavian Journal of Public Health 37(5): 475–480.

Chance

(1990) The Inupiat and Arctic Alaska: An Ethnography of Development. New York: Holt Rinehart & Winston.

Dagsvold

Møllersen

Blix

(2020) Clinicians’ assumptions about Sami culture and experience providing mental health services to indigenous patients in Norway. Transcultural Psychiatry 57(2): 363–374.

10.

Dagsvold

Mollersen

Stordahl

(2015) What can we talk about, in which language, in what way and with whom? Sami patients’ experiences of language choice and cultural norms in mental health treatment. International Journal of Circumpolar Health 74(1): 26952.

11.

Dagsvold

Møllersen

Stordahl

(2016) “You never know who are Sami or speak Sami” Clinicians’ experiences with language-appropriate care to Sami-speaking patients in outpatient mental health clinics in Northern Norway. International Journal of Circumpolar Health 75(1): 32588.

12.

Dyregrov

Berntsen

Silviken

(2014) The need for and barriers to professional help: A qualitative study of the bereaved in Sámi areas. Suicidology Online 5(1): 47–58.

13.

Good

Hannah

(2015) “Shattering culture”: Perspectives on cultural competence and evidence-based practice in mental health services. Transcultural Psychiatry 52(2): 198–221.

14.

Gracey

King

(2009) Indigenous health part 1: Determinants and disease patterns. The Lancet 374(9683): 65–75.

15.

Gubrium

(2005) Introduction: Narrative environments and social problems. Social Problems 52(4): 525–528.

16.

Heatta

(2016) Sami Norwegian National Advisory Unit on Mental Health and Substance Abuse(SANKS). Available at: https://conference2016.lowitja.org.au/assets/G-Heatta-presentation.pdf (accessed 16 April 2019).

17.

Institute for Health Metrics and Evaluation (2016) Norway: State of the Nation’s Health: Findings From the Global Burden of Disease. Seattle: IHME.

18.

Javo

Rønning

Heyerdahl

(2004) Child‐rearing in an indigenous Sami population in Norway: A cross‐cultural comparison of parental attitudes and expectations. Scandinavian Journal of Psychology 45(1): 67–78.

19.

King

Smith

Gracey

(2009) Indigenous health part 2: The underlying causes of the health gap. Lancet (London, England) 374(9683): 76–85.

20.

Kirmayer

(2012a) Cultural competence and evidence-based practice in mental health: Epistemic communities and the politics of pluralism. Social Science & Medicine (1982) 75(2): 249–256.

21.

Kirmayer

(2012b) Rethinking cultural competence. Transcultural Psychiatry 49(2): 149–164.

22.

Kirmayer

(2018) Ethno‐and cultural psychiatry. The International Encyclopedia of Anthropology. Epub ahead of print 5 September 2018. DOI: 10.1002/9781118924396.wbiea2362

23.

Klausen

(2017) Relational insight and user involvement in the context of Norwegian community mental health care. A narrative analysis of service users’ stories. PhD, UiT Norges Arktiske Universitet, Norway.

24.

Klausen

Karlsson

Haugsgjerd

, et al. (2016) Motherhood and mental distress: Personal stories of mothers who have been admitted for mental health treatment. Qualitative Social Work: Research and Practice 15(1): 103–117.

25.

Klausen

Karlsson

Haugsgjerd

, et al. (2017) Narrative performances of user involvement among service users in mental health care. Narrative Inquiry 27(1): 149–168.

26.

Matheson

Bombay

Anisman

(2018) Culture as an ingredient of personalized medicine. Journal of Psychiatry & Neuroscience : JPN 43(1): 3–6.

27.

Mathisen

(2017) Brukermedvirkning i distriktspsykiatriske sentre-et interaksjonsteoretisk perspektiv. Praktisering av” brukermedvirkning” i fellesrom og rapporter [User participation in community mental health centers -an interaction theory perspective. Practicing “user participation” in common rooms and reports]. PhD Thesis, The Arctic University of Norway, Norway.

28.

Mikkelsen

(2013) Nature and people in the pite Sámi c area [Natur og mennesker I det pite Sámiske området. Masteroppgave i kultur og profesjon. Institutt for lærerutdanning og pedagogikk, fakultet for humanoria, samfunnsvitenskap og lærerutdanning]. Master’s Thesis, University of Tromsø, Norway.

29.

Minde

Nymo

, et al. (2016) Open the medical room: How indigenous patients’ cultural knowledge appears in the meetings with the health care providers during the rehabilitation process. In: Hart

Burton

Hart

(eds) International Indigenous Voices in Social Work. Cambridge: Cambridge Scholars Publishing, pp. 83–101.

30.

Minde

(2005) Assimilation of the Sámi -implementation and consequences. Journal of Indigenous People’s Rights 3: 3–31.

31.

Ministry of Labor and Social Affairs (2000-2001) Report No.55 on Sámi Politics. Oslo: Arbeids- og Sosialdepartementet.

32.

Møllersen

Sexton

Holte

(2005) Ethnic variations in the initial phase of mental health treatment: A study of Sami and non‐Sami clients and therapists in Northern Norway. Scandinavian Journal of Psychology 46(5): 447–457.

33.

Nergård

(2011) Når slutter en koloniprosess? [When does a colonial process end?]. In: Jentoft

Nergard

Røvik

(eds) Hvor Går Nord-Norge? Tidsbilder Fra en Landsdel i Forandring [Where Does Northern Norway Go? Time Images from a Changing Region]. Stamsund: Orkana Akademisk, pp. 119–128.

34.

Nymo

(2011) Helseomsorgssystemer i Sámi ske markebygder i nordre Nordland og Sør-Troms: praksiser i hverdagslivet: “en ska ikkje gje sæ over og en ska ta tida til hjelp” [Health care systems in Sámi happen in rural areas of northern Nordland and Sør-Troms: Practices in everyday life: “One should not give up and one should take the time to help”]. PhD, Universitetet i Tromsø [University of Tromsø], Norway.

35.

Riessman

(2008) Narrative Methods for the Human Sciences. Thousand Oaks: Sage.

36.

Sjolander

(2011) What is known about the health and living conditions of the indigenous people of northern Scandinavia, the Sami? Global Health Action 4: 8457. DOI:10.3402/gha.v4i0.8457

37.

Sorlie

Nergard

(2005) Treatment satisfaction and recovery in Saami and Norwegian patients following psychiatric hospital treatment: A comparative study. Transcultural Psychiatry 42(2): 295–316.

38.

Statistics Norway (2019) Sámi Statistics 2019. Oslo: Statistisk Sentralbyrå.

39.

Stoor

JPA

Berntsen

Hjelmeland

, et al. (2019) “ If you do not birget [manage] then you don’t belong here”: A qualitative focus group study on the cultural meanings of suicide among indigenous Sami in arctic Norway. International Journal of Circumpolar Health 78(1): 1565861.

40.

Turi

Bals

Skre

, et al. (2009) Health service use in indigenous Sami and non-indigenous youth in North Norway: A population based survey. BMC Public Health 9: 378.

41.

Willox

Stephenson

Allen

, et al. (2015) Examining relationships between climate change and mental health in the Circumpolar North. Regional Environmental Change 15(1): 169–182.

“We belong to nature”: Communicating mental health in an indigenous context

Abstract

Keywords

The Sámi

Research concerning mental health care within Sámi contexts

Data and methods

The participants

Narrative approach and thematic analysis

Findings

Theme 1: The expectation of raising children to be independent

Sunna

Theme 2: The importance of accepting and recognizing the Sámi identity

Ole-Per

Sara, Ole-Per’s wife, continued

Arja

Arja

Theme 3: The need to live in close relations with nature and family

Theme 4: The right to be in the Sámi mode

Reliability and validity

Discussion: Communicating mental health in an indigenous context

Footnotes

Acknowledgments

Declaration of conflicting interests

Funding

ORCID iD

Notes

References