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

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.

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 Sa´mi population appears to be similar to that of the general population, but studies indicate that the indigenous Sa´mi 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 Sa´mi. We present research concerning mental health care within Sa´mi 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 Sa´mi are indigenous people living in Norway, Sweden, Finland and the Kola Peninsula in Russia. The Sa´mi population is estimated to be approximately 100,000 people (Dagsvold et al., 2015). Most Sa´mi people live in Norway; the estimated Sa´mi population in Norway is approximately 55,000 (Statistics Norway, 2019), and approximately 25,000 members of this population speak a Sa´mi language (Ministry of Labor andSocial Affairs,2000-2001). In this study, we concentrated on participants who self-identified as Northern, Southern or Lule Sa´mi. 1 Beginning in the mid-19th century, the Sa´mi 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 Sa´mi people. This period of colonization led to the loss of the Sa´mi language, stigmatization and discrimination (Blix et al., 2013). The Norwegian Sa´mi policy has gradually shifted from the assimilation ideology, and currently, Sa´mi 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 Sa´mi 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 Sa´mi are still in a decolonization process (Nerg˚ard, 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 Sa´mi understandings of health and illness revealed that the Sa´mi 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 Sa´mi 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 Sa´mi. 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 Sa´mi'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 Sa´mi people in Norway is complicated; some Sa´mi areas have strong and ethnic support and a high density of Sa´mi, different languages have equal status and several Sa´mi institutions reside there. In other regions, the Sa´mi are a minority, and there is less support of their culture. Prejudice and conflicts regarding land rights and Sa´mi language are a part of everyday life (Turi et al., 2009). A study by Stoor et al. (2019) showed that Sa´mi understand suicide among Sa´mi people as related to historical and ongoing oppression, negative treatment of Sa´mi by other Sa´mi, shortage of culturally adapted mental health care, issues within Sa´mi networks and traditional cultural values. Related to this complex context, Sa´mi 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 Sa´mi 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 Sa´mi Norwegian National Advisory Unit on Mental Health and Substance Abuse (SANKS 2 ). SANKS has the national responsibility for the development and delivery of services in mental health and addiction for the Sa´mi people in Norway. The main goals of the SANKS is to ensure equitable services and good accessibility for all groups of Sa´mi 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 Sa´mi 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 Sa´mi language and were from reindeer herding families. All participants spoke Norwegian or Swedish. One participant was learning Sa´mi language, and her family had left the reindeer herding life. Only participants who had experiences with culturally adapted Sa´mi 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 Sa´mi, Lule Sa´mi and Southern Sa´mi. 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 meaningmaking 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 Sa´mi men and women in need of mental health services. The following themes are identified as prerequisites contributing to user involvement within the Sa´mi context: (1) the expectation of raising children to be independent, (2) the importance of accepting and recognizing the Sa´mi identity, (3) the need to live in close relations with nature and family, and 4) the right to be in the Sa´mi mode.
Theme 1: The expectation of raising children to be independent. Important Sa´mi values and norms within the culture are applied in the traditional way of raising children. Several participants underlined that the primary aim of Sa´mi 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 Sa´mi 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. 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 Sa´mi 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 Sa´mi 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 Sa´mi. 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: The Sa´mi identity was not only Sara's project. The need for acceptance was also two-sided; the traditional Sa´mi 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).

Ole-Per
Arja. The following excerpt describes a situation in which an individual's Sa´mi identity was recognized by the local community, but some of the majority community 3 questioned her Sa´mi identity. A psychiatrist asked Risten, Arja's sister, about her experiences as a Sa´mi 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 Sa´mi, 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 na´rrideapmi, cf. Balto (2005). Na´rrideapmi is an indirect form of communication that has several functions in Sapmi. First, na´rrideapmi helps master social interactions and become aware of feelings. Feelings can be addressed through humor and in a joyful manner through na´rrideapmi. Na´rrideapmi 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 na´rrideapmi.

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 Sa´mi 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 Sa´mi 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 Sa´mi 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. [. . .] Sa´mi 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 Sa´mi 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 Sa´mi 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 "Sa´mi 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 Sa´mi core values. In contrast, the participants defined the "Sa´mi mode" as being in balance with nature, performing physical work and addressing one's problems. While speaking to each other, Sa´mi 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 Sa´mi patients to abandon some of their core values. Arja, a Finnish Sa´mi 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 Sa´mi.
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 Sa´mi 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 "Sa´mi mode" in another way as follows: Interviewer: It takes a while to get into the Sa´mi mode. Sjolander (2011) emphasized that several specific health problems among Sa´mi are related to reindeer herding. Most problems are related to marginalization, poor knowledge of reindeer husbandry, and knowledge about the Sa´mi culture in the majority population. Consistent with Sjolander (2011: 9), we agree that "the most sustainable measure to improve health among reindeer-herding Sa´mi would be to improve the conditions of the reindeer husbandry and the Sa´mi culture". We find that the most important element in this work is to respect the Sa´mi 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 Sa´mi reindeer herders in Norway and the impact of such oppression on mental health care within Sa´mi 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 Sa´mi mental health care users. The participants' stories are interwoven in accordance with Sa´mi 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 Sa´mi 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 Sa´mi mode. These prerequisites belong in a dimension between individualistic -collectivistic values in the Sa´mi cultural identity (Javo et al., 2004). While child rearing is connected to individualistic autonomy, the Sa´mi identity and the relation to nature and family are related to collectivistic strength. Being in the Sa´mi 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 Sa´mi 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 Sa´mi identity and its complexity related to individualistic and collectivistic dimensions. One way to improve the mental health condition of reindeer-herding Sa´mi 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.