Translating and Implementing a Mindfulness-Based Youth Suicide Prevention Intervention in a Native American Community Thao N. Le & Judith M. Gobert
Journal of Child and Family Studies ISSN 1062-1024 J Child Fam Stud DOI 10.1007/s10826-013-9809-z
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Author's personal copy J Child Fam Stud DOI 10.1007/s10826-013-9809-z
ORIGINAL PAPER
Translating and Implementing a Mindfulness-Based Youth Suicide Prevention Intervention in a Native American Community Thao N. Le • Judith M. Gobert
Springer Science+Business Media New York 2013
Abstract The present study is a feasibility study, aimed at investigating whether a mindfulness-based prevention intervention can be translated and implemented in a Native American youth population. Guided by the adaptation process model, a mindfulness youth suicide prevention intervention was developed and implemented in a Native American school. One group of eight youth, ages 15–20, participated in a 9-week pilot of the intervention. Results of the mixed-methods process and outcome evaluation suggest that the intervention is acceptable to Native American youth, with positive indications in terms of better selfregulation, less mind wandering, and decreased suicidal thoughts. It became clearly evident that a collaborative and indigenous research framework is both required and necessary to ensure feasibility and sustainability of mindfulness-based interventions. Keywords Native American youth Mindfulness Suicide Prevention intervention
Introduction Suicide presents a significant social and public health problem, especially among Native American communities. Recent research estimates that Native American youth and young adult ages 15–24 years have the highest suicide rate
T. N. Le (&) Family and Consumer Sciences, University of Hawai’i at Manoa, Honolulu, HI 96822, USA e-mail:
[email protected] J. M. Gobert Confederated Salish Kootenai Tribes, Pablo, MT, USA
of any cultural or ethnic group in the United States, in fact, 2.5 times higher than the national average (Centers for Disease Control and Prevention (CDC) 2012). Suicide is also the second leading cause of death among this age group and population (CDC 2012). Unfortunately, current suicide prevention/intervention programs for Native American youth remain extremely limited. Among those identified for Native American youth, only four programs have been deemed as being evidence-based (effective or promising) by SAMHSA’s National Registry of EvidenceBased Practices and Programs, and only two of the four were developed specifically for and with the Native American community. The most cited and well-known is the American Indian Life Skills Development which was based on the Zuni Life Skills Development curriculum (LaFromboise and Pitney-Howard 1995). While Native American youth are particularly at high risk for suicide because of cumulative risk factors including historical and intergenerational trauma, alcohol use and dependency disorders, family substance use, high rates of poverty and unemployment, and family violence (Beals et al. 2005), Birnbaum and Birnbaum (2008) contend that suicide among indigenous population such as Native Americans reflects an underlining spiritual crisis that requires a culturally grounded spiritual solution. Mindfulness and Suicide Prevention Mindfulness is a potentially effective prevention intervention strategy for suicide by providing individuals with important tools to recognize and manage self-destructive thoughts and emotions along with developing the capacity ‘to be’ with difficult thoughts and emotions (distress tolerance). Individuals who are at-risk or suffer from suicidal tendencies often have difficulties regulating their emotions
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and discursive thoughts. Psychological processes associated with aversion (i.e., suppression), excessive attachment (i.e., elaboration), or mental model building and rumination (perseverative cognition) that result in biases and distortion are often common responses to stimuli (Williams 2010). As a result, individuals experience difficulties in managing impulses and responding adaptively. Mindfulness essentially involves the ability to attend to stimuli (sensory phenomena, thoughts, events, experiences) on a moment-to-moment basis without judging and reacting to the stimuli (Baer 2003; Brown and Ryan 2003). Awareness of the present moment and non-judgmental acceptance of this awareness are key elements (Bishop et al. 2004), as well as metacognitive awareness and decentering ability (e.g., Shapiro et al. 2006). Collectively, this results in a dispassionate mindset that enables one to see and perceive clearly and objectively, without the usual mind chatter (commentaries, thoughts about the past and future, self-evaluations, judgments) that often clouds perception and perspectives. Individuals are able to perceive and experience thoughts, feelings, and events without clinging to or rejecting them, enabling greater equanimity. As Shapiro et al. (2006) stated, mindfulness accelerates the natural developmental shift in perspective that allows one to observe the content of one’s consciousness, that is, the capacity to engage objectively in one’s internal experiences. Instead of being identified with one’s thoughts and feelings (e.g., anger, sadness, despair, hopelessness), one is able to stand back and observe these thoughts, feelings, and sensations dispassionately. Greater attentional and interoceptive (physical sensation) awareness and honing of metacognition in turn has implications in terms of brain and neurological functioning. Specifically, neuroscience studies has revealed that mindfulness can result in less activation of the default mode network (DMN), the network that is key in self-referential processing (cognitiveaffective representation of the self), and engages brain regions that process viscera-somatic information, enabling better self and emotional regulation (Farb et al. 2010; Holzel et al. 2011; Kerr et al. 2013). For suicidal individuals, this facilitates their ability to see thoughts as mental events (‘‘I am no good’’ as simply a thought) rather than the thoughts being enmeshed with self and the meaning of self (‘‘I am no good’’ means I, this idea/concept of permanent self, is no good). Mindfulness has been shown to be effective in more than 125 clinical randomized trials with adults, for conditions ranging from physical ailments to mental health conditions such as depression and anxiety (Ebert and Sedlmeier 2012; Grossman et al. 2004; Hoffman et al. 2010). Studies with respect to mindfulness and suicide have been very limited, with the majority of the work being conducted by Mark Williams and his colleagues at Oxford.
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They’ve examined the feasibility and effectiveness of mindfulness-based cognitive therapy for recurring suicidal persons (Hargus et al. 2010; Williams et al. 2006), and for those who suffer from chronic forms of depression (Barnhofer et al. 2009). Williams and his colleagues contend that mindfulness meditation practices paired with cognitive behavioural therapy techniques are highly promising in increasing suicidal depressed participants’ metacognitive awareness and decentering skills (Hargus et al. 2010; Williams and Swales 2004), including—reductions in thought suppression (Hepburn et al. 2009). Linehan (1993) also incorporated mindfulness techniques in her development of Dialectical Behavior Therapy (DBT) to treat borderline personality disorder and those who engage in repeated self-harming behavior. Although quite therapeutically intensive, DBT has been shown to be highly effective at reducing self-harming behavior (Linehan et al. 2006). In contrast to studies with adult populations, studies of mindfulness with children and adolescents remain limited although steadily emerging (Burke 2010; Meiklejohn et al. 2012). Randomized controlled studies with elementary and middle school students indicate improvements on executive functioning (Flook et al. 2010), attention and behavioral problems (Semple et al. 2010), and with adolescents, improvements on stress and anxiety (Biegel et al. 2009). In a recent review of mindfulness programs for K-12 students, Meiklejohn et al. (2012) noted that while the current evidence base for mindfulness-based interventions for youth is limited, the studies to date suggest that such an approach for children and adolescents is promising, feasible, and acceptable. However, no studies thus far have examined the feasibility and acceptability of mindfulness as a prevention/intervention for youth suicide, or with Native American youth. Here, we are not necessarily considering mindfulness as a therapeutic, tertiary level intervention program to treat depressed suicidal individuals (although this exploration is certainly warranted), but as a primary or secondary intervention strategy to decrease youth risk factors (e.g., stress, impulsivity, distress intolerance) by increasing youth’s self-regulation and emotional regulation skills (protective, resiliency factors). Mindfulness and Native American Spirituality Birnbaum and Birnbaum (2004) assert that individuals suffer because they do not see themselves as they truly are and are disconnected from their spiritual ground of being and their own inner wisdom, while Garroutt et al. (2003) suggest that Native Americans who have a strong and committed relationship to their native spirituality exhibit significantly less suicidal behavior than their peers. Mindfulness, which we contend is consistent with Native
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American ancient practices and ways of being, becomes a potential way for youth to connect to their inner wisdom and to the traditional, tribal ways of being. Linehan (1993) observed that even in severely disturbed mental health patients, there is still the presence of the ‘wise mind,’ and being able to connect to wise mind can attenuate suicidal tendencies and behaviors. Mindfulness may be a particularly appropriate prevention approach for suicide because it resonates with Native American spirituality in several important ways. First, one of the core components of mindfulness involves cultivating ‘right’ intentions including openness, acceptance/nonjudgment, kindness, and compassion. One is instructed to engage with whatever arises in oneself be it thoughts, emotions, sensations, even disturbing ones, with these virtues. Eventually, it becomes natural, even habitual, to extend these virtues to others, including family members, tribal members, and the world at large. Being virtuous, righteous, and balanced is a consistent theme in many cultural practices in indigenous communities. Second, in Native American traditions, sacred ceremonies like the vision quests, sweat lodges, drummings, sun dances, etc. are intended as alignment practices, to attune to one’s highest intentions. These very rich, deeply sensory embodied experiences are meant to bring one’s awareness to the present moment in a way that facilitates connecting with and honoring the land, nature, ancestors, and family lineage. In fact, these intense somatic focusing practices that encourage being in the body and sensitizing one’s senses may also serve to hone cognitive regulation and metacognition (Kerr et al. 2013). These practices also illustrate the theme of interconnectedness and inter-being which are salient in mindfulness practices. Third, in mindfulness, one is instructed to attune and attend to an object (e.g., breath, sound) as an anchor that eventually becomes a guide into the doorway of deep silence leading to deep insight—insight into the nature of reality and one’s role and meaning in the world. In many indigenous communities, practices are embedded into the fabric of the community that emphasized the importance of silence and ability to engage in deep listening. Interestingly, when the first author asked what this intervention should be called, the second author said Restoring the Native American Spirit. Mindfulness also resonates with Native American ways of being in that an important consideration in suicide prevention intervention concerns perceived obstacles and barriers that may prevent individuals from receiving the necessary services, stemming from perceptions of shame, stigma, embarrassment, social disapproval, or not wanting to be a burden to their family or community (Freedenthal and Stiffman 2007; Sarche et al. 2011). Native Americans may be hesitant to seek or receive services due to issues of confidentiality, particularly if they reside in small communities with limited community health resources
(De Couteau et al. 2006). Indeed, accessibility and feasibility are important considerations in the uptake of practices, particularly for suicide prevention (Abram et al. 2008). However, Hodge et al. (2009) contend that many Native Americans report unmet mental health needs not because of access or lack of available of mental health services, but because many of the current therapeutic, clinical interventions reflect Western worldviews that are inconsistent with Native American culture and epistemology. Many Native American communities view health and well-being as a complex interplay of different factors, processes, and relationships including spirituality. Mindfulness as a suicide prevention strategy may hold less of a stigma as compared to other suicide prevention/ intervention programs and models as it can be packaged as a stress reduction or well-being intervention, or as a Native American spiritual/cultural practice, rather than as a mental health treatment. In one study with Native American youth, embarrassment and stigma were reasons for youth avoiding and receiving mental health services (Freedenthal and Stiffman 2007). Further, Native Americans are more likely to prefer and to use traditional healing practices, or services that use traditional knowledge for mental health issues (Beals et al. 2005; Walls et al. 2006). Indeed, interventions that consider the unique cultural factors of the population of interest are more likely to be well received and effective (Goldston et al. 2008). The Present Study For our present study, we had two aims. The first aim was to engage in adaptation/translation of a mindfulness curriculum for cultural relevancy with Native American traditions and spiritual practices. We collaborated with esteemed Elders, community practitioners, and cultural committee members in this effort. The second aim was to conduct a feasibility study of the culturally adapted curriculum with a sample of Native American youth from a Native American school. Relatedly, our primary research questions included: (1) Can a mindfulness-based suicide prevention intervention be effectively integrated into a Native American school? (2) Will Native American youth be receptive to the concepts and practices of mindfulness? and (3) Will school administrators perceive the intervention to be beneficial for improving youth’s behavior and well-being?
Method Process of Translation The original curriculum comes from Mind Body Awareness Project (MBA), a 10-module, MBA curriculum based
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on John Kabat-Zinn’s Mindfulness-Based Stress Reduction program (MBSR, Kabat-Zinn 1990) and theoretical grounding of social-emotional learning that was specifically developed for difficult-to-reach, resistant-to-treatment, at-risk youth populations. This curriculum has primarily been used with detained and incarcerated youth in California (Himelstein et al. 2012), many of whom are of ethnic minority (African American and Latino predominately), but has never been used with the Native American or indigenous youth populations. Guided by the Adaptation Process Model (Domenech-Rodrı´guez and Weiling 2004), the process of cultural adaptation included multiple phases. In phase one, intervention developer (first author) met with a group of opinion leaders (Native American elders) upon introductions by a key tribal stakeholder (second author) to present and discuss the concept of mindfulness, and how it may/may not resonate with the tribe’s traditional practices and culture. Subsequently, meetings with each of the three Cultural Committees were also conducted, as well as presentation to members of Tribal Council. Once Tribal Council provided their approval, and Elders provided their blessing to move forward, intervention developer proceeded to phase two. A key component of obtaining Elders’, Council’s, and Cultural Committees’ buy-in in the early stage of this process was collaborating with a tribal champion (second author) who not only understood the issues of the community in terms of the suicide risk factors, but was also a well-respected leader in the community who was able to move the project forward, and continually educated the larger community about the project. In the second phase, the intervention developer and tribal champion connected with and obtained permission from the school site, a Bureau of Indian Education school serving students in grades 7–12th, for the pilot study. In addition, Tribal Social Service worked closely with the intervention developer to examine the curriculum for cultural syntonic in the content aspect. This included carefully examining the goals and concepts of the curriculum, the specific metaphors used to ‘‘bridge bodily-grounded experiences with culturally shaped narratives’’ (Kirmayer 2012, p. 253), the adequacy of language and cultural stories, the mindfulness practices and experiential activities, the context of delivery, as well as person match (i.e., who should be the facilitators from the community). It should be noted that the mindfulness intervention was to be part of a current on-going, larger comprehensive suicide prevention strategy called the Circle of Trust Suicide Prevention Program in the community. The Circle of Trust includes coordination of suicide prevention services and gate-keeping activities among various social services and mental health agencies on the reservation, as well as a social media campaign that display words of wisdom from Elders in various public service announcements in local
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radio, television, and posters. It was deemed that this intervention would be available to all youth, as a primary/ secondary intervention to prevent youth suicide by building youth’s stress-reducing and resiliency skills. Additional Modules During phase two, based on feedback and input from the community including Tribal Elders, three additional modules (mindful listening; mindfulness of nature; aligning with vision) were developed as well as revisions and expansion of the previous modules. Because delivery was to occur at school as an elective class, homework assignments were developed for each of the modules. Additional verbiage and detailed narratives were also expanded for each of the modules. In total, there were nine modules in the culturally adapted version including mindful breathing; mindful listening; mindfulness of nature; mindfulness of body; mindfulness of thoughts; mindfulness of emotions; cultivating compassion and empathy; judgment and forgiveness; and aligning with vision. Delivery Framework While there were revisions in the content of the modules, the framework for delivery remained consistent to the original curriculum. For instance, the class was conducted in council style, a Native American practice, whereby everyone sits together in a circle to encourage and practice speaking and listening from the heart. Key elements for council included establishing confidentiality and trust, while creating a sacred, dedicated space and time for the group process. Agreements among participants for council were established during the first week. Another important aspect of the framework concerns the quality and experience of the facilitators. It is emphasized that the facilitators must come from the community, as facilitators who reside and live in the community are more likely to understand and can share their own personal experiences that resonate with the youth participants (e.g., intergenerational trauma, racism, suicide in the community). Facilitators are required to be able to model authenticity and vulnerability, to model learning ‘to be’ with what is, and to conduct the group with open-heartedness, in a more guiding relationship style. In phase three of the project, mindfulness facilitators were identified and recruited by the community partner. All of the facilitators were members of Confederated Salish and Kootenai Tribes (CSKT) and had strong ties to CSKT youth culture. As this mindfulness intervention was rather novel for the community, none of the facilitators had a formal mindfulness practice; however, all noted that they engaged in some form of informal mindfulness practices including meditation, sweating in lodges, beading, fishing,
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or hiking on sacred trials. One in particular noted that she engages in mindfulness practices on a daily basis, and has led youth council groups and summer language camps where she introduced various forms of informal mindfulness practices to tribal youth. Having an established, formal mindfulness meditation practice was not a prerequisite to be facilitator as this would have been an unreasonable requirement for this community. Additionally, sustainability was a goal for the project, and this required recruiting, selecting, and nurturing potential community leaders who could serve as facilitators. Once the facilitators were identified, mindfulness group facilitation and curriculum training were offered to both the recruited facilitators as well as to the larger tribal community. The training included a two and a half days of intensive mindfulness and mindfulness group facilitation. In addition, after each session with the youth, the first author provided debriefing and coaching sessions with the facilitators, lasting between 1 and 3 h per week over 9 weeks. Finally, phase three also included identifying appropriate measures for the evaluation, and collaborating with the community partner to develop the research design, protocol, and to obtain human subject approval from the Native American college as well as the intervention developer’s own institutional IRB. The mindfulness class was offered as an elective class at a Native American school that occurred four sessions per week, 55 min per session, over 10 weeks; the first week was devoted to enrollment and doing baseline assessments. The class was facilitated by at least two facilitators and was restricted to ten students per class. Each session opened with a smudge and/or prayer, followed by a check-in, then the following content in various order: specific mindfulness practice, story, metaphor, experiential activity, discussion, and ending with a check-out and prayer. Students were given weekly homework assignments that included trying out the mindfulness practices that they learned for the week, and recording their experiences in reflection papers. It should be noted that all of the youth at the school are currently screened for suicidality and are referred to the tribal licensed clinician for therapy as needed. A safety protocol for the mindfulness facilitators was implemented that detailed the steps to be taken should any adverse reaction occur during the session or if they suspect any among the participating youth. During the course of the study no adverse reaction occurred, and no youth had to be referred to the clinician. Participants The sample for our feasibility study included members of the CSKT of the Flathead Reservation located in rural northwestern Montana, within the boundaries of Lake
County. CSKT is comprised of the Bitterroot Salish (Squelix’u), the Pend d’Oreille (Qlispe’), and the Kootenai (Ktunaxa) Tribes. Participants were recruited through an assembly announcement during the first day of class at CSKT’s Two Eagle River School to youth ages 15–20. The class was offered in the morning for 55 min Monday through Thursday for 9 weeks conducted by at least two trained facilitators. Once youth signed up for the class, they were then asked to participate in the pilot study. Both parental consent and youth assent were obtained. In total, eight youth (mean = 17 years old, range = 15–20; five males) signed up for the class and participated in the pilot study. Procedures Participants were administered a baseline survey during the first week of class, and a termination survey during the last week of class. In addition, open-ended interviews were conducted with the participants at the end of class, to assess for intervention satisfaction and recommendations. During intervention implementation, facilitators debriefed with the intervention developer regularly over multiple times during the week. This allowed for coaching and technical assistance on the mindfulness concepts and practices, and delivery of the curriculum. Facilitators provided weekly personal reflections of the group experiences, and the intervention developer conducted open-ended interviews with the facilitators at the end of the intervention. Analyses consisted of content coding of thematic categories for the qualitative data, and paired t-tests for the quantitative data. Measures For the survey administered to the participants, measures included the following: Demographics including age (date of birth), gender (1 = male; 2 = female), and ethnicity (1 = American Indian/Native American with possible subcategories of Salish, Kootenai, and Pend d’Oreille; African American; European American; Hispanic; Asian/ Pacific Islander; and Mixed). Mindfulness in terms of present moment awareness (or lack of) was assessed using two-items that asked ‘‘How often, in the past week, did you think about something other than what you were doing?’’ and ‘‘How often, in the past week, were you focused on what you were doing?’’ Response options included always/frequently, sometimes, and rarely. These two items were based on a similar twoitem measure used in a study conducted by Epel et al. (2012). They found these two items to be significantly associated with telomere aging as a correlate of stress, and the measure to have adequate reliability and construct validity with respect to mind wandering, an aspect of mindfulness.
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Healthy Self-Regulation (West 2008) was comprised of 12-items that ask participants about their ability to modulate their feelings, behaviors, and thoughts. Examples of the items include ‘‘I need to get revenge if I am insulted;’’ ‘‘my anger comes too fast for me to stay in control;’’ ‘‘I am known to lose my temper;’’ and ‘‘I have a healthy and natural way to relax.’’ Participants responded to these items using a six-point Likert scale ranging from 1 = almost never to 6 = almost always. Some items are reversed score, but a higher score on the scale reflects greater ability for self-regulation. The measure has shown adequate reliability including test–retest (a = .84) and positive relations with well-being indicators (West 2008). Teenage Impulsivity was measured via four items of the Teen Conflict Survey (Bosworth and Espelage 1995). These items measure the frequency of impulsive behaviors (e.g., lack of self-control, difficulty sitting still, trouble finishing things) with higher score suggesting greater impulsivity. The scale has been shown to have adequate internal and test–retest reliability among middle school and ethnic minority population (Bosworth et al. 1999; McMahon and Washburn 2003). Suicidality was assessed using the Patient Health Questionnaire, PHQ-9 (Kroenke et al. 2001). PHQ9 is a 9-item brief, valid, and reliable measure of depression severity with one item that specifically asks about suicide such as ‘‘thoughts that you would be better off dead or of hurting yourself in some way.’’ Scores of 5 indicate mild, 10 moderate, 15 moderately severe, and 20 severe depression. The measure has been shown to have adequate psychometric properties (sensitivity and specificity) with the adolescent population (Richardson et al. 2010). In the termination survey only, two items were included that asked whether skills were gained to help participants deal with stress, ‘‘overall, by being in the class, do you feel that you have gained some important skills to help you deal with stress?’’ and one item that asked whether participants made new friends and strong connections, ‘‘overall, by being in this class, do you feel you have made new friends and strong connections?’’ Response for both items ranged from 1 = yes, very much so, 3 = neutral, to 5 = no, not very much. On a weekly basis, facilitators were asked to provide personal reflections to the following five questions: (1) What was the group dynamic for this week, and what contributed to the group dynamic? (2) What activities worked, didn’t work, and why? (3) What experience(s), event(s), or participant(2) stood out? (4) What helped me to be effective and to connect with the youth? and (5) What was a hindrance/barrier? Finally, at the end of the intervention, researcher conducted open-ended interviews with all the participants, facilitators, and school administrators, to ask about satisfaction with the intervention,
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implementation challenges, impact, and their recommendations for changes. The interviews were recorded, transcribed verbatim, and inputted into NVivo, a qualitative data software, for analysis. Analysis of the qualitative data occurred in three phases. In phase one, first author and one graduate research assistant read through some of the interviews and facilitators’ weekly reflections and engaged in open coding (Strauss and Corbin 1998), selecting key words and phrases that reflected potential categories and ideas. First author and research assistant then met to discuss agreements and disagreements, and finalized the coding categories (phase two). During the third phase, the research assistant read through all the interviews and facilitators’ reflections again and coded the data using the agreed upon coding categories, followed by a review by the first author. Axial coding was then used to link categories to reveal the themes (e.g., implementation challenges, recommendations, helpfulness, receptivity).
Results Because of the small sample size, we used an ideographic approach for data analysis using graphic displays of the pre-post score to visually illustrate the changes for each participant. Figure 1 illustrates the changes on the teenage impulsivity measure, and indicates a slight trending toward lower impulsivity from pre to post, as three youth showed remarkable improvement while three youth showed slight increases. Figure 2 illustrates the changes associated with the self-regulation measure, and indicates improvement for four youth, no changes for two, and a slight decrease for one. On the mindfulness indicators, youth showed significant improvement in terms of reporting that they were able to engage in the present moment and less mind wandering (Fig. 3); however, there were no differences pre to post on their ability to stay focused on a task (25 % indicated that they always, and 65 % indicated that they somewhat did so). With respect to suicide ideations, at pre-test, 44 % reported several days to more than half the days to thinking that they thought that they were better off dead or thoughts of hurting oneself in some way, while at post-test, 100 % responded not at all to the item. In addition the depression score improved slightly (pre-test mean = 9.00, range 2–19; post-test mean = 7.83, range 1–15). Youth’s Receptivity Seventy-one percent responded very much so, and 29 % responded somewhat so to the question about whether they gained some important skills to help them with stress. Similarly, 86 % were affirmative about making new friends
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63%
Pre (n=8) Post (n=7)
60% 50% 37%
40% 30% 20%
14%
14%
10% 0%
0% always, frequently
Fig. 1 Paired profiles of pre and post values for impulsivity for individual participants
sometimes
rarely
Fig. 3 Pre versus post responses to item ‘‘How often, in the past week, did you think about something other than what you were doing?’’
‘‘Activities help me to be mindfulness because I get into many arguments.’’ Youth provided responses in their homework assignments, and this helpfulness theme continued under the category of practice uptake: ‘‘I liked tracking thoughts in mindful acceptance.’’ ‘‘Head feels tingly, headache when I feel ignored.’’ ‘‘I love forgiveness. I like to try and start every day new as if no one has done me wrong. You can’t move to a new town everyday so you have to be at some sort of peace with the people surrounding you.’’ ‘‘I judge myself a lot, all the time…loving kindness meditation helps.’’
Fig. 2 Paired profiles of pre and post values for self-regulation for individual participants
and forming strong connections with others by being in the class. From the qualitative data with the youth, one theme that was most salient was helpfulness, and under helpfulness, mindful breathing came up most frequently, followed by improved awareness, relaxation, and calmness: ‘‘Meditating helps my hyperness and helps me focus. It’s only hard for me to get started on meditating after that I’m good and when I am supposed to concentrate on breathing I just imagine a big blue circle growing & shrinking with each breath. So many times in my life I have had to remember to just breathe.’’ ‘‘I never thought the mind was capable of such extraordinary images that they can be incredibly relaxing.’’ ‘‘My breathing helps me stay still & focus, my thoughts slow down.’’
Under the theme of receptivity, many youth said that choosing (and the ability) to share personal histories was very important in addition to establishing trust and enjoying the class. ‘‘I feel good about the sharing circle.’’ Under recommendations, all indicated that having the class in the morning was good as it helped them set the tone/mood for the day, and to keep the class co-ed. ‘‘The mindfulness class is first period makes for a great start.’’ ‘‘Breathing, focusing, it’s a good way to start my day!’’ Facilitators’ Reflections From the facilitators’ weekly personal reflections, various activities came up under the theme of helpfulness including storytelling, mindful eating, mindful breathing, and games to illustrate mindfulness concepts. Under the theme of implementation challenges, difficulties primarily centered
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around interpersonal dynamics among the facilitators (i.e., perceptions of the other facilitators’ ability to effectively guide the group, and to work as a team in terms of coordinating activity implementation; miscommunication and disagreements often resulted in feelings of frustration that required intervention by the intervention developer and the tribal mental health counselor who supported the intervention) and facilitators’ ability to deal with participant’s disconnection and disengagement from an activity or practice. They did however acknowledge that each participant will have a different way of internalizing and resonating with the particulars of each module. In terms of positives, a common theme was group resonance, particularly as it relates to trust building among the participants, and between the participants and facilitators. They pointed to specific examples of participants’ disclosure and opening up. ‘‘…after the loving kindness meditation, T was more involved than ever…the cultural stories led to great discussions…worked great.’’ ‘‘holding the ice cubes…led to a great discussion on how it felt for each of us to sit with difficult emotions. S did great participating.’’ For the recommendation theme, facilitators mentioned needing more preparation time and more extensive training to fully experience each activity. Overall, both facilitators and school administrators felt that the intervention was a positive and transformative experience for the youth; in particular, several mentioned that the group process was instrumental in helping them to develop friendships and in helping them to open up and share more than usual. Facilitators also reported that it was transformative for them too, and how much they enjoyed connecting with the youth, learning with the youth, and deepening their own mindfulness practice. All expressed enthusiasm and eagerness to continue the intervention. In fact, before her retirement, the principal of the school instituted the mindfulness class as an official elective.
Discussion The primary aims of this feasibility study were to explore whether a mindfulness-based intervention could be translated and culturally adapted for Native American youth, whether the resultant mindfulness-based suicide intervention could then be effectively integrated into a Native American school, and whether youth participants would be receptive to the concepts and practices of mindfulness. The preliminary results, both quantitative and qualitative, suggest that participants were highly receptive to the intervention and to the mindfulness practices. Overall, youth
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reported acquiring greater ability to focus attention, greater awareness of their thoughts and emotions, and being able to ‘sit’ with difficult emotions and thoughts. Several also acknowledged the healing nature of quietness, silence, and of tuning into nature. All youth reported that having the intervention as their first class was most helpful in helping them to start the day, and they highly recommended keeping the class to first period. Youth, facilitators, and administrators also reported that the intervention was effective in terms of facilitating relationships and in strengthening connections. The group process was particularly helpful in creating a safe space where youth felt comfortable to be vulnerable and to share; everyone noted that the opportunity to share was truly valuable. With respect to mindfulness as a prevention intervention for suicide, stressors, both general (poverty, family history of substance use) and unique cultural ones (loss, discrimination, prejudice, isolation, historical, intergenerational trauma), have been implicated in higher rates of suicide among Native American communities (LaFromboise et al. 2007; Yoder et al. 2006). Native American youth often experience multiple and accumulated stressors that can deplete physical, cognitive, and emotional reserve capacity, resulting in lower well-being and greater risk for depression and suicide. It is also well known that significant neurobiological changes such as increased limbic reactivity and development of reasoning occur in adolescence (Casey 2013). Stress, however, can impair brain development in adolescence, particularly in the areas associated with executive functioning and regulation of emotions/impulses (Romeo 2013). Over time, the habitual, automatic, unconscious responses to stress can be one of high impulsivity, low distress tolerance, and poor emotional/self-regulation, and difficulties in these areas are considered underlining risk factors in adolescent selfharming behaviors and suicidal attempts (Zlotnick et al. 2003). Neuroimaging literature has also illustrated the inherent ‘stickiness’ of the default, self-referential brain structures and processes to link stimuli (thoughts, emotions, events) to self and to attribute meaning and value to self (Holzel et al. 2011). This DMN is heightened in highly stressed, traumatized individuals, with known attendant degradation of prefrontal cortex areas involved in executive functioning and skillful decision making (Daniels et al. 2010). As a tool, mindfulness can strengthen Native American youth capacity to recognize and manage selfdestructive, suicidal thoughts and behavior by decoupling stimuli (thoughts, emotions) with self, and by strengthening their metacognitive and decentering skills to simply observe and notice, which in turn can modulate relevant brain structure and function toward a more adaptive state (e.g., greater coherence, connectivity). With the increasing evidence around mindfulness as a modulator of brain
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plasticity (Holzel et al. 2011), Michael Yellow Bird has proposed that mindfulness can in fact be a form of neurodecolonization (Yellow Bird 2013). With respect to the curriculum itself, it is important to acknowledge that it is age and culturally appropriate in terms of the experiential mind–body activities, mindfulness practices, stories, and metaphors. Starting and ending each class with a prayer, and a smudge at the beginning, was very important in terms of including a culturally relevant and meaningful ritual. It set a sacred and respectful tone for the class. Future studies will need to explore whether the youth’s acquired skills actually translate to the real world settings with their family members, with their peer groups, their tribal community, and the community at large. The next phase of this project is to refine the curriculum based on the feedback received from youth in this pilot, the inputs and experiences of the community facilitators, as well as inputs and consideration of expert mindfulness facilitators. It became clearly evident that while recruiting facilitators from the community is required for sustainability and buy-in, continued professional training on mindfulness practices, both formal and informal are absolutely necessary. Community facilitators need to be steeped in their own mindfulness practices. The difficulty becomes how much training is necessary and sufficient? Crane et al. (2011) contend that at least one to 3 years of ‘‘personal’’ mindfulness practice is required before one can be trained to lead mindfulness groups. Others suggest the possibility of a shorter time frame for personal practice (e.g., Shawyer et al. 2012); however, engagement in at least some formal, intensive training like the 8-week MBSR (Kabat-Zinn 1990) course in concert with some personal practice seems to be a non-negotiable, required prerequisite. Unfortunately, not all communities have the luxury of being able to send their members to a mindfulness retreat, or to a formal mindfulness facilitator training. While on-line options are now available, it is still not clear which trainings/retreat is effective, how much training is sufficient, or the minimum of personal/formal practice plus formal facilitator training is needed. The field of mindfulness training, particularly for K-12 students is still young with findings preliminary (Meiklejohn et al. 2012), let alone empirical findings that may be relevant and culturally meaningful to ethnic minority communities. The challenge for many Native American communities also includes finding the appropriate community member who already has the generic professional competencies along with the motivation, commitment, and time to be trained and to become experienced mindfulness facilitators. Because of their competencies and connections in the community, many of these community professionals are already vastly stretched and in demand.
Another important lesson gleaned from this effort concerns the importance of community-based partnerships in the translational process and in instituting a new intervention in the community. Partnerships between tribes and researchers require an orientation to research that is both culturally-based and community-centered. In this project, partners worked collaboratively on every step of the project and decision making despite geographic distance being a barrier as it was mutually acknowledged that a core objective of the research is to provide benefits to the community. Although partners had not previously collaborated before, the individual passion of the project partners and commitment to make the project sustainable, as well as communications and actions centered on respect, patience, and flexibility enabled the project to proceed and prosper. All subsequent data analyses, reporting, sharing, and narrative of the results were approved by community members and Tribal Council. Indeed, programs that draw from indigenous knowledge are more likely to be successfully implemented and sustained (Feinberg et al. 2008; Wallerstein and Duran 2006), as well as programs that have undergone cultural adaptation (Griner and Smith 2006). Unlike traditional research, the rationale and philosophical assumptions for indigenous research is that the research project itself can be a healing process or a form of sustainable self-determination (NCAI Policy Research Center and MSU Center for Native Health Partnerships 2012). Stories and narratives from the research are particularly valued, and can serve as important learning tools. There is also an implicit assumption that the research is reciprocal—that knowledge and power is shared equitably between the researchers and the community, and that the community can be enriched by the process. Interestingly, research could even serve as a process to recover and reclaim indigenous wisdom: ‘‘We should be able to look for them (indigenous wisdom), define them—because nothing is lost. In fact, we still have a lot of knowledge that was left to us by our ancestors. It’s still there; we just have to go and look for it. That’s what we’re all about— research.’’ (Pualani Kanakaole Kanahele 2011) As noted earlier, the community overall embraced the mindfulness project as it was apparent that mindfulness is an indigenous way, and this research merely recovered it. Hence, the title for the intervention, Restoring the Native American Spirit, is apropos and was specifically named by a tribal community member (second author). This member viewed mindfulness as a potential way to recover and restore traditional ways of wisdom that has historically been stripped and disallowed by the American colonization process (see Turner and Pope (2009), for description of the American colonization process and mental health
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consequences). In this regard, there is potential for science to support emancipatory knowledge (Habermas 1968) by bringing healing and self-determination in a way that is consistent with Native American values and to restore cultural practices that facilitate wisdom and balance. Interestingly, the literal translation of mindfulness practices within Theravada Buddhism means ‘the way of the elders’(http://forestsangha.org/history/). Restoring the Native American Spirit could also represent restoring the way of the Native American elders.
(emic perspective). The indigenous community may not necessarily choose to sustain the program/intervention because the scientific ideas of effectiveness is of little value and consequence to the community stakeholders; conversely, indigenous community may sustain the program regardless of the scientific evidence because they perceived important outcomes that resonate with their values and perspectives. As such, research-community partnership can afford many opportunities to broaden horizons, perspectives, and paradigms.
Limitations and Future Directions
Conclusion
As with all small pilot studies, there are limitations that need to be acknowledged. The results, for instance, need to be interpreted with regard to the potential for selection effects given that the intervention was offered as an elective class; students who participated in the intervention may be different from those who did not participate in areas such as academic motivation, family dynamics, substance use, among others. Nonetheless, many of the results were in a general positive direction and suggest the need for a broader scientific study of the effects of mindfulness-based intervention for Native American/indigenous youth. Such a future study would require random assignment, ideally with an active control group, so internal validity can be established, as well as objective indicators in addition to self-report and other report measures. Although intensive and expensive, randomized controlled longitudinal studies would provide evidence on intervention durability as well as ability to distinguish between normal developmental changes versus changes attributed to the intervention. The study is also quite limited due to the very small sample size, which in a feasibility study, is not meant to be generalizable or to make causal inferences. After the cultural adaptation process, an aim of this study was to then examine the mindfulness intervention with respect to safety, acceptability, and uptake. As a feasibility study, the results suggest that mindfulness-based intervention is acceptable and translatable for Native American youth. However, given that there are more than 566 federally recognized tribal governments across the United States (Bureau of Indian Affairs 2013), additional studies with other Native American/indigenous communities are certainly needed. Finally, the issue of paradigm is also of noteworthy consideration. In best research practices, researchers are required to use academically-derived, psychometrically sound measures and scientific methodology. Yet, this ‘‘etic’’ perspective may not necessarily coincide with what indigenous community deem or value as being effective
Although mindfulness-based interventions have been well established, well researched, and well documented for a variety of psychological, physiological, and behavioral problems for adults, along with fewer studies concerning children and adolescents, this study is particularly innovative in it focuses on Native American youth. To our knowledge, a mindfulness intervention for Native American youth has not been adapted, translated, and tested. This feasibility study suggests that mindfulness-based prevention intervention for indigenous communities is one that can be culturally valid and sustainable in real world settings, particularly if approached and implemented collaboratively.
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Acknowledgments This project was supported by a grant from the American Psychological Foundation and funding from the Colorado Injury Control Research Center. We are also grateful for the support and input from CSKT Tribal Council, Tribal Social Services Department, Circle of Trust Suicide Prevention Program, Tribal Elders, Cultural Committees, Two Eagle River School, Dean Furukawa, and Becky Ereaux. We are also indebted to the Mind Body Awareness Project for providing curriculum expertise and training, and to the youth and facilitators who opened their hearts and minds. Lastly, we express our appreciation to the anonymous reviewers who provided their valuable comments and edits.
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