Promoting Mental Health and Well-Being in Native Communities

May 28, 2021

A new Psychological First Aid Guide — produced by the Johns Hopkins Center for American Indian Health in partnership with UNICEF USA — offers mental health support strategies for COVID-19 responders working in Native communities, where children and families have been disproportionately affected by the pandemic. In this Q&A, the project leads explain the guide's relevance for anybody seeking guidance on how to deal with the lingering effects of a very difficult year.

COVID-19 has been devastating for American families, children and communities. Loss of loved ones, isolation, loss of income and fear are triggering mental health conditions or exacerbating existing ones — not just for children but for their families and for the frontline workers responsible for their care. Particularly for children and adolescents, anxiety, depression and other stress-related problems can threaten the ability to grow up healthy and happy. Violence and poverty before and following the onset of this public health crisis can impact people’s emotional health, physical health and social development. And if exposed in early childhood, these experiences can hamper a child’s brain development.

A UNICEF USA partnership to promote mental health and well-being

This is why UNICEF USA has been working since the beginning of the pandemic to support mental health and psychosocial well-being in the U.S., leveraging UNICEF’s global expertise and partnering with local organizations. In 2020, UNICEF USA partnered with the Johns Hopkins Center for American Indian Health (CAIH) to support mental health and psychosocial interventions in tribal and Urban Native communities.

Anxiety, depression and other stress-related problems can be particularly hard on young people. UNICEF USA partnered with the Johns Hopkins Center for American Indian Health to develop resources to support mental health and well-being in tribal and Urban Native communities where children and families have been disproportionately affected by the COVID-19 pandemic. @ Ed Cunicelli

As part of that effort, CAIH developed — and has just released — a first-of-its-kind guide to Psychological First Aid for COVID-19 first responders. The guide includes resources and information specifically around supporting children and other family members. 

We caught up with CAIH Associate Director Victoria O’Keefe and CAIH Research Associate Fiona Grubin to get the full story behind the project. The following are excerpts from the conversation.

Please tell us a little bit about yourselves and your roles in putting this guide together.

VICTORIA O’KEEFE: Osiyo! That’s ‘Hello’ in the Cherokee language. I'm an enrolled citizen of the Cherokee Nation of Oklahoma and a Seminole Nation descendant. I'm the Mathuram Santosham Endowed Chair in Native American Health at Johns Hopkins University, an assistant professor at the Johns Hopkins Bloomberg School of Public Health and an associate director at CAIH. I joined the team in 2017. I'm a clinical psychologist by training and my community-based research really focuses on strengths-based suicide prevention and mental health promotion with Indigenous communities. For the guide I served as a co-principal investigator, overseeing the process from the beginning and working with our team of Native collaborators.

FIONA GRUBIN: I’m a CAIH Research Associate focusing on strengths-based approaches to promoting positive mental health and prevention strategies. I actually started working with the center as a student in 2018 when I was pursuing my master’s in public health at Johns Hopkins. I have been working on mental health research and research with Indigenous communities since I was an undergraduate student. For the Psychological First Aid [PFA] guide, I served as project coordinator — organizing every piece, facilitating our meetings and working collaboratively with everyone on our team to produce this resource.

So why develop a separate guide, when one already exists? The CAIH guide is based on the Basic Psychological Skills Guide for COVID-19 First Responders released in May 2020 by the Inter-Agency Standing Committee’s Mental Health and Psychosocial Support Reference Group [IASC is a coordinating body within the UN system that represents UN and non-UN organizations], correct?

VICTORIA O’KEEFE: Yes, ours is a cultural adaptation of that source material. After COVID-19 hit, we quickly saw the need to develop mental health resources tailored to Native communities. There are 574 Tribal Nations and Urban Native communities — all very diverse. COVID-19 has disproportionately impacted many tribes and communities throughout the United States. This is due to a number of factors, including an ongoing legacy of colonization, oppression and structural racism, all of which continue to widen health and mental health inequities among American Indians and Alaska Natives compared to other groups.

Many of our communities hold cultural values around connectedness. There's a strong sense of communal solidarity and responsibility that we've seen throughout the COVID pandemic and currently with the amazing vaccine distribution efforts of tribes and Urban Native health programs. This is the context within which we developed the Psychological First Aid guide with UNICEF USA’s support. There’s also an online training course that goes with it, which we’re looking to get accredited.

A new resource for first responders offers tools and strategies that could be useful for anyone dealing with mental stress

The guide is framed as a resource for frontline workers, but it seems the tools and strategies could be useful for a lot of people.

FIONA GRUBIN: To take a step back for a moment, Psychological First Aid is designed to equip first responders, health care and other frontline workers with basic mental health and behavioral health management skills to meet the needs of those affected by a disaster. Anything that’s widely stressful or traumatic. The pandemic certainly qualifies.

An illustration from the Psychological First Aid guide adapted for use in Native communities by the Johns Hopkins Center for American Indian Health. The guide offers strategies for supporting mental health and well-being, including detailed guidance on what to do when you encounter a child who is in serious distress, supporting family members through listening and connecting loved ones with additional resources. © Illustration by Joelle Joyner

And we know that throughout the pandemic, mental health needs have increased all over the country and the world. We know that frontline workers who've been responding and working through this pandemic have faced many challenges and are also experiencing more symptoms of depression and anxiety and other mental health distress.

So with this in mind, we set out to create something that could quickly deliver mental health help, to support healthy coping, to help people manage their pandemic-related stress. We adapted this PFA guide and training specifically for frontline workers who are responding to the pandemic in American Indian and Alaska Native communities to support their needs in a way that is culturally relevant and appropriate.

That said, you’re absolutely right: certainly anyone who is interested in bolstering their mental health and psychosocial support skills might find these resources useful. That is our hope, for sure. There are a bunch of suggested coping strategies that we definitely think could be useful for anyone, since the pandemic has been stressful for us all.

VICTORIA O’KEEFE: The themes are universal too. Indigenous cultural values are rooted in the idea that we are all interconnected, and that caring for others is important, and not just caring about other people but caring about all beings, the environment, etc. Just imagine if everyone in the world lived by similar values like this? What would public health look like, globally, if we all lived in this way? We always say Indigenous communities have a lot to teach the world about public health.

What was your process for creating the guide [which is free and publicly available, and can be downloaded here]?

VICTORIA O’KEEFE: We convened a collaborative group of Indigenous health and mental health workers and leaders from diverse tribes and who work in different settings, across urban, rural and reservation contexts. We wanted to ensure that this resource would be relevant to a diverse group of tribes and Native peoples all across the country. The goal was to provide a culturally relevant and Native-led mental health resource. We worked off the IASC guide, asking our collaborators to go through each module and tell us which parts they liked, what we should keep, what we should change. We met nine times (virtually) over five months. It was an iterative process.

Excerpt from Johns Hopkins Center for American Indian Health's guide to Psychological First Aid for COVID-19 first responders working in Native communities, developed in partnership with UNICEF USA to provide resources for children and families in the U.S. who have been disproportionately affected by the pandemic. © Johns Hopkins Center for American Indian Health

FIONA GRUBIN: We did two focus groups too, where we brought in American Indian frontline workers doing this work in rural and urban communities. They talked about burnout, compassion fatigue, their fears of getting COVID and bringing it home to their loved ones. They talked about some of their main coping strategies — getting outside, finding creative ways to stay connected to family and friends, practicing gratitude.

We synthesized all of this feedback. And while it was very pragmatic for us to hear directly from frontline workers, I think it was powerful for our participants as well, to be able to hear from others who were having similar experiences. I think they found it useful to have a space to share and reflect and interact with each other. 

So what are some of the guide's key points or takeaways?

VICTORIA O’KEEFE: For a lot of Indigenous communities, mental health, emotional health, physical health and spiritual health are all connected. You can't talk about one without talking about the others. And so that interconnectedness is reflected. Another key takeaway is gratitude and deep respect for frontline workers, who day in and day out are taking care of communities.

Psychological First Aid interventions support relaxation, self care and rapport building 

FIONA GRUBIN: I want to emphasize that PFA is not a replacement for care from a clinical psychologist or a therapist. Still, there are many people who can benefit from PFA interventions that support relaxation, self care, and rapport building to make positive connections with people. Another important takeaway is the power of listening and making other people feel heard.

What is the significance of the wavy lines that appear on the guide’s title page and elsewhere?

VICTORIA O’KEEFE: Those lines are meant to represent the abalone shell, which has many important uses in some tribal cultures and communities. The abalone shell is used by some to carry traditional medicines. The lines in this guide symbolize the connection of relationships and with the land.

An abalone shell's natural lines inspired the design that illustrates CAIH's Psychological First Aid guide aimed at COVID-19 frontline workers in Native communities. @ Photo illustration by Design de Plume

Now that the guide is out there, what will your team do next?

FIONA GRUBIN: We’re about to start recruiting people to help us conduct a full evaluation of the guide as a resource. We want to see if it’s actually helpful to people. Even though psychological first aid is evidence-informed, there’s actually a dearth of data around impact.

As I mentioned earlier, Psychological First Aid is meant to be implemented right after a disaster. The pandemic is a little different, because there is no “after” — at least not yet. But I think a lot of people are finally getting a chance to catch their breath, and sometimes that's when mental health stress catches up to you. So hopefully this is really timely.

I think the guide is particularly helpful for people who don't really have a background in mental health, but have a really strong urge to help their friends or their family or the people they work with. Sometimes you don’t know where to start, or maybe you’re afraid of doing more harm than good. This guide can help — not just now but in future.

Top photo: Three generations of a family, citizens of the Navajo Nation, are photographed in Central Chinle Agency in Arizona. Interconnectedness — between children and Elders, within communities and beyond — is explored in a new guide to Psychological First Aid produced by a team of experts at the Johns Hopkins Center for American Indian Health in partnership with UNICEF USA. The guide's tools and resources, available at, are relevant to anyone who has a friend or family member who is struggling with mental health issues — pandemic related or not. @ Ed Cunicelli