Cultural Approaches to Promote Indigenous Mental Health: Weaving Healthy Families.

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Published before final editing as: J Ethn Cult Divers Soc Work. 2025 Jun 4:10.1080/15313204.2025.2510218. doi: 10.1080/15313204.2025.2510218 Cultural Approaches to Promote Indigenous Mental Health: Weaving Healthy Families Catherine E O’Connor 1 , Katherine P Theall 2 Author information Copyright and License information 1 Professor, Tulane University School of Social Work, 127 Elk Place, New Orleans, LA 70112 2 Professor, Tulane University School of Public Health ✉ (Corresponding author, Formerly McKinley/Burnette, Catmckinley@tulane.edu ) PMC Copyright notice PMCID: PMC12470361  NIHMSID: NIHMS2089114  PMID: 41018558 The publisher's version of this article is available at J Ethn Cult Divers Soc Work Abstract Pilot results from the culturally relevant Weaving Healthy Families (WHF) prevention program were examined to see how U.S. Indigenous adolescents and adult’ program participation was associated with changes in mental health outcomes, namely dysfunctional attitudes among adolescent (aged 12–17) and adults, and adult symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD). A nonexperimental one-group longitudinal design and generalized estimating equations model were to examine results from 24 adolescents and adults in eight Indigenous families. Promising preliminary results indicated significant declines in dysfunctional attitudes and symptoms of anxiety, depression, and PTSD. Keywords: alcohol abuse, substance abuse, mental health, health disparities, anxiety, depression, PTSD, health equity, Native Americans, American Indians, Indigenous peoples As consequences of historical oppression , institutional, structural, and intergenerational structures of cultural disruption, settler colonialism, and historical traumas ( Burnette & Figley, 2017 ; McKinley, Ka’apu, et al., 2020; Sam et al., 2022 ), U.S. Indigenous peoples (scope here limited to Native Americans) experience a disproportionate burden of, anxiety, depression, suicide, substance misuse, and posttraumatic stress disorder (PTSD) across the life course ( Burnette & Figley, 2016 ; Gone & Trimble, 2012 ; Ka’apu & Burnette, 2019 ; Liddell & Burnette, 2017 ). Sex differences have been found to pervade across mental and behavioral health outcomes ( Ka’apu & Burnette, 2019 ). Culture, family, spirituality, and Indigenous worldviews are fundamental promotive factors for Indigenous mental health wellness ( Fast & Collin-Vézina, 2019 ; Gone & Kirmayer, 2020 ; Nelson & Wilson, 2017 ; Wexler & Gone, 2012 ). Within Indigenous worldviews, mental health tends to be characterized as degrees of as balance or imbalance across sociocultural, spiritual, relational, physical, and psychological dimensions of wellness ( Nelson & Wilson, 2017 ; Walters et al., 2009). Culturally centered interventions are needed to promote health and mental health equity among Indigenous peoples ( Dickerson et al., 2020 ). The Weaving Healthy Families (WHF), prevention program, or the Chukka Auchaffi’ Natana (in the Choctaw Language), is a culturally and family-focused intervention which promotes mental health, wellness, and resilience while preventing their primary risks of substance use and violence (McKinley & Theall, 2021). The purpose of this research study is to examine the pilot test for sex-specific postintervention changes dysfunctional attitudes and symptoms of anxiety, depression, and PTSD. The disproportionate rates mental health conditions, such as anxiety, depression, suicide, and PTSD are associated with substance misuse and family violence ( Bassuk et al., 2006 ; Masten & Monn, 2015 ; Tolan et al., 2006 ), and elevated mortality rates ( Whitesell et al., 2012 ). Exposure to trauma, intimate partner violence, child abuse tends to be higher due to a context of settler colonial historical oppression ( Evans-Campbell et al., 2012 ; Gone & Trimble, 2012 ; Ka’apu & Burnette, 2019 ; Robin et al., 1997 ). Trauma exposure varies by sex, with women being exposed to greater severity and frequency of trauma across the life course ( Evans-Campbell et al., 2012 ; Ka’apu & Burnette, 2019 ). A history of trauma poses risk for substance misuse, anxiety, depression, and PTSD ( Ka’apu & Burnette, 2019 ; Robin et al., 1997 ). Research on Indigenous youth ages 9 to 18 has indicated elevated rates of substance misuse ( Gone & Trimble, 2012 ; Sarche & Spicer, 2008 ), with reported rates higher than the national rates for nearly all substances ( Stanley et al., 2014 ). substance misuse is not only a primary risk for death, it tends to be comorbid with depression, anxiety, PTSD, and all psychiatric conditions ( Brave Heart et al., 2016 ; Ka’apu & Burnette, 2019 ; Moghaddam et al., 2014 ; O’Connell et al., 2005 , 2006 ; Rieckmann et al., 2012 ; Robin et al., 1997 ; Serdarevic et al., 2019 ; Tann et al., 2007 ), which are also disproportionately high among Indigenous peoples ( Ka’apu & Burnette, 2019 ; McKinley et al., 2021 ). Suicide is highly associated with depression, as two thirds of those who complete suicide also experience depression ( American Association of Suicidology, 2009 ). Dysfunctional attitudes, as measured by the dysfunctional attitudes scale (DAS), are primary and well-established cognitive factors ( Beck, 1979 ; D’Alessandro & Burton, 2006 ) that predict the onset, relapse, and reoccurrence of major depressive episodes ( Brouwer et al., 2019 ). Not only do dysfunctional attitudes play a key role in the development and prognosis of depression, but gender differences have also been found to be related to these attitudes ( Qin et al., 2020 ). Depression and anxiety are well-established comorbid disorders ( Jacobson & Newman, 2017 ). The scant existing research has placed the prevalence of depression and anxiety (especially generalized anxiety disorder, or GAD) between 10% and 30% of the Indigenous population ( Evans-Campbell et al., 2012 ; Gone & Trimble, 2012 ; Ho et al., 2015 ; McKinley et al., 2021 ). Moreover, Indigenous peoples with depressive and anxiety disorders were twice as likely to experience substance misuse than those without these disorders ( Rieckmann et al., 2012 ). Trauma, such as intimate partner violence and adverse childhood experiences–both of which are disproportionately high among Indigenous people–is also associated with depression and anxiety symptoms ( McKinley et al., 2021 ). In this same study, a quarter of the sample experienced clinically significant depressive symptoms, and almost 20% experienced clinically significant anxiety ( McKinley et al., 2021 ). This rate far exceeds the 8% of all U.S. adults over the age of 20 (5.5% of males and 10.4% of females) who have reported clinically significant depressive symptoms ( Brody et al., 2018 ) and the 8% of U.S. adults who have reported clinically significant symptoms of generalized anxiety ( Jordan et al., 2017 ). Need for Culturally Grounded Approaches to Promote Wellness According to McNamara and Naepi (2018 , p 304), psychology is “…a historical inheritor of colonized ways of thinking and knowing … still remains in danger of inadvertently propagating colonialist agendas.” McNamar & Naepi (2012) call for the integration of Indigenous worldviews. Yet, mental and behavioral health interventions for Indigenous peoples have lacked cultural relevancy ( Dickerson et al., 2020 ; Liddell & Burnette, 2017 ; Thomas et al., 2009 ). Treatments conventionally take a non-Indigenous approach and tend to be less effective ( Burnette & Figley, 2016 ; Gone & Trimble, 2012 ), indicating an urgent need for culturally grounded intervention. Limiting Western approaches is their tendency to approach mental and behavioral health as separate from physical, emotional, mental, and spiritual health ( West et al., 2012 ). Indigenous peoples’ worldviews tend to place primacy on the interconnections across the psychological, emotional, physical, spiritual, and environmental dimensions of wellness ( Burnette & Figley, 2017 ; Rowan et al., 2014 ), making holistic and strengths-based interventions warranted ( Burnette & Figley, 2016 ; Ka’apu & Burnette, 2019 ; West et al., 2012 ). Culturally targeted interventions focusing on more holistic understandings may be more effective for Indigenous peoples ( Dickerson et al., 2020 ; Hill, 2003 , 2009 ; Szlemko et al., 2006 ). Successful interventions often incorporate cultural programming, such as sweat lodges and talking circles, along with conventional treatment services ( Rowan et al., 2014 ). Despite substantial growth and development ( Dickerson et al., 2020 2), culturally grounded and family-focused interventions available to prevent mental health outcomes associated with substance misuse and violence among Indigenous peoples remain limited ( Dickerson et al., 2020 ; Ka’apu & Burnette, 2019 ; Liddell & Burnette, 2017 ). “Indigenous peoples” is a term describing heterogeneous groups thought to be the first inhabitants of the United States and who share a history of being affected by colonization. Through approximately 400 treaty agreements with sovereign federally recognized tribes, a trust responsibility requires the U.S. government to provide for Indigenous peoples’ well-being and health in perpetuity ( Bureau of Indian Affairs, 2022 ; Le & Aptekar, 2019). Evidence this agreement is not being upheld is evident through the severe underfunding of Indian Health Service (the primary provider of health services for Indigenous peoples, whose per capita spending is approximately 70% of funding for the prison population; Le & Aptekar, 2019) and mental health inequities ( Indian Health Service, 2019 ). Chukka Auchaffi’ Natana/Weaving Healthy Families Program The WHF program represents the culmination of over a decade of community-based participatory research (CBPR) with over a thousand Indigenous peoples (McKinley & Theall, 2021; McKinley et al., 2019 ). The WHF program is a culturally grounded and empirically informed program that prevents substance misuse through psychoeducation and by providing healthy skills to offset at-risk ATOD use. The program aims to prevent symptoms of anxiety, depression, suicide, and PTSD by promoting protective factors and resilience while providing skills for emotional regulation and addressing the dysfunctional attitudes and behaviors that may contribute to these disorders (McKinley & Theall, 2021; McKinley et al., 2021 ). The WHF program was developed by tailoring the Celebrating Families! evidence-based program ( National Association for Children of Alcoholics, 2017 ; White Bison, 2022 ). The WHF program integrates the Indigenous-based framework of historical oppression, resilience, and transcendence (FHORT), which follows the recommended wellness approach and frames risk and protective factors across macro-, meso-, and micro-ecological levels ( Burnette & Figley, 2017 ). The WHF program centers the FHORT by understanding AUD and the mental health dimensions of wellness in relation to the structures of historical oppression , which includes past historical traumas such as: forced relocation and removals, cultural genocide, using alcohol and other substances to both disrupt and undermine culture and manipulate land agreements and treaties, and policies that forced assimilation and cultural and religious suppression, such as those enacted during the boarding school era ( Burnette & Figley, 2017 ). Historical oppression is inclusive of the continued, chronic, and intergenerational forms of contemporary oppression, including the imposition of chronic poverty and socioeconomic disparities, elevated exposure to trauma and at-risk environments, and racism and discrimination–all of which have given rise to extant AUD and mental health disparities ( Burnette & Figley, 2017 ; Evans-Campbell et al., 2012 ; Gone & Trimble, 2012 ). Indeed, structural oppression from historical oppression, including chronic socioeconomic disparities, racism, sexism, and education discrimination, have been found to be risks for substance misuse, anxiety, depression, and suicide ( Ka’apu & Burnette, 2019 ; Wexler & Gone, 2012 ). The WHF program and FHORT center resilience — how people adapt to adversity and challenges—which is affected by culturally relevant risk factors that worsen outcomes, promotive factors that serve as strengths regardless of circumstances, and protective factors that buffer against challenges ( Burnette & Figley, 2017 ; Masten & Monn, 2015 ; McKinley & Theall, 2021). A body of work on Indigenous resilience, which can be explored across cultural contexts, has emerged ( Weaver, 2022 ). According to FHORT, a balance of risk and protective factors explains and predicts the extent to which a person reports resilience and wellness, or the integration and balance of mental, physical, emotional, physical, social, environmental, and spiritual health ( Burnette & Figley, 2017 ). The adapted WHF is a 10-session cognitive-behavioral and psychoeducational prevention program that integrates the FHORT by: targeting key areas of wellness; using the medicine wheel approach for mental, physical, social, and spiritual wellness; promoting psychological and family resilience, preventing violence and family conflict by providing skills for positive communication through culturally based talking circles; and integrating holistic Indigenous teachings on health (McKinley & Theall, 2021). Each 2.5-hour session is facilitated by community health representatives (CHRs) from the community of interest and begins with a family meal, nutrition, and health component to promote communication and promotive family rituals (McKinley & Theall, 2021). Entire families attend the program, and after the family meal, participants go to their respective age groups (i.e., parents, youth ages 12–17, youth ages 8–11, youth ages 5–7), where they receive the same content in developmentally and culturally tailored ways. The topics of each session include: (a) healthy living according to the medicine wheel; (b) healthy communication; (c) emotional expression and defenses; (d) alcohol, tobacco, and other drug (ATOD) use; (e) how ATOD use affects the whole family; (f) setting goals; (g) making healthy choices and problem-solving; (h) boundaries and healthy relationships; (i) resilience; and (j) celebrating and reviewing the lessons learned in culturally appropriate ways. The past decade of empirical research is integrated and infused throughout the program, with the sessions developed nationally under the guidance of community advisory boards (McKinley & Theall 2021; McKinley et al., 2019 , 2022). Past preliminary research has indicated improvements in holistic outcomes, including the prevention of ATOD use in youth; emotional regulation; health behaviors; community, family, and psychological resilience; social support; family functioning; and a reduction in depressive symptoms and intimate partner violence (McKinley & Theall, 2021). This article extends this work to examine mental and behavioral factors using a longitudinal pilot data set focused on dysfunctional attitudes, and symptoms depression, anxiety, and PTSD. Our preliminary hypothesis was dysfunctional attitudes and symptoms of depression, anxiety, and PTSD would decrease following the WHF program and these outcomes will vary by sex. Methods Research Design This research is part of a broader pilot whose outcomes related to substance misuse and violence may be found elsewhere (McKinley & Theall, 2021). The scope of this inquiry to limited to the mental health outcomes. As part of a larger research study (McKinley & Theall, 2021; McKinley et al., 2019 ), this one-group nonrandomized intervention pilot program utilized a one-group nonexperimental longitudinal pretest, posttest (i.e., immediately after the intervention), 6-month postintervention, 9-month postintervention, and 12-month postintervention with a convenience sample of eight Indigenous families. We used repeated measures regressions with generalized estimating equations (GEE; Schober & Vetter, 2018 ) to examine significant changes over time in the following key outcomes: dysfunctional attitudes (adults and adolescents ages 12–17), and adult symptoms of depression, anxiety and PTSD. Although all family members ages 5 and above were included in the intervention, we limited our scope to parents whose alcohol use and mental health outcomes were assessed and their children ages 12 and above. Inclusion criteria for the families included: (a) having an Indigenous caregiver in the family; (b) having children ages 12 or above; (c) the availability to attend all sessions; and (d) the ability to complete online surveys with assistance, if needed. Families with active no-contact orders or safety situations were excluded, along with those who had substance use disorders requiring a higher level of care. Pilot results of the WHF program indicated promising findings warranting further investigation (McKinley & Theall, 2021). Using word-of-mouth sampling, we worked with cultural liaisons and a community advisory board to recruit eight families, all of whom completed all sessions and program components (McKinley & Theall, 2021). The structure of each of the ten 2.5-hour sessions involved a family eating a meal prepared by an Indigenous member and receiving a nutrition teaching before going to developmentally tailored age groups (i.e., parents, youth ages 12–17, youth ages 8–11, youth ages 5–7). These groups began with a talking circle for Indigenous-grounded centering and sharing. Each group then received parallel session content before joining their families to reinforce the teachings in fun and experiential ways. Two CHRs facilitated each age group’s sessions, with two Indigenous lead CHRs coordinating and running intervention operations. Although these lead CHRs did not facilitate sessions, they completed weekly fidelity checks, and assisted with set-up, materials, meals, and site oversight. Each CHR received two 3-day training courses to facilitate the curriculum. Setting and Sample The setting for this program is a federally recognized tribe in the southeastern United States, whose name and identifying information we exclude to honor tribal confidentiality agreements. This setting has its own law enforcement, behavioral health, family and social services, criminal justice, and educational systems. In this context, the WHF program location was determined in conjunction with the community advisory board (CAB), who settled on a church large enough for the 8 families. Overall, 35 participants were recruited to participate in the study; this includes adults ages 18 years and older ( n = 14), adolescents from ages 12 to 17 ( n = 10), children from ages 8 to 11 ( n = 8), and young children from ages 5 to 7 ( n = 3). The current analysis only includes the 24 adult and adolescent respondents from the larger study sample as the outcomes of interest were not assessed in the younger participants. Respondents represented eight families and provided 120 total observations across the five waves of data collection. Among these 24 respondents, 54.17% ( n = 13) identified as female and 45.83% ( n = 11) identified as male. Seventy-five percent ( n = 18) identified as Native American. Most of the adult sample identified as female (64.29%, n = 9), partnered (64.29%, n = 9), employed (91.67%, n = 11), and having at least a high school education (78.58%, n = 11). The average income for the majority of sample (92.86%, n = 13) ranged from $25,001 to $50,000. The household size ranged from two to eight family members, with an average household size of 6.60 ( SD = 2.31) and the average number of biological children in the household at 3.65 ( SD = 2.02). The average age of the adult sample was 33.56 ( SD = 9.14) Demographic characteristics of the sample are presented in Table 1 . Table 1. Participant Demographics (n = 24) Demographic characteristics Adult sample ( n = 14) Adolescent sample ( n = 10) n (%) n (%) Participant sex Male 5 (35.71) 6 (60.00) Female 9 (64.29) 4 (40.00) Age at pretest ( M ) 34 (range 19–48) 13.80 (range 12–17) Yes 12 (85.71) 10 (100.00) No 2 (14.29) - Relationship status Married 6 (42.86) - Single 4 (28.57) - Cohabitating 3 (21.43) - Divorced 1 (7.14) - Annual household income - $15,000-$25,000 1 (7.14) - $25,001-$50,000 13 (92.86) - Financial difficulty Very difficult 2 (14.29) - Somewhat difficult 7 (50.00) - A little difficult 5 (35.71) - Not at all difficult 0 (0.00) Working full-time 11 (91.67) - Education - Some high school 3 (21.43) - High school/GED 3 (21.43) - Some college 6 (42.86) - Bachelor’s degree 2 (14.29) - M (SD) Average household size at pretest 6.14 (range 2–8) - Average number of biological children 3.71 (1.94) - Open in a new tab Note . Reported from the adult and adolescent sample at pretest only. Financial difficulty indicated: “In your opinion, how difficult is it for you and your family to live on your current monthly income at this time”. Data Collection Prior to data collection, we acquired university institutional review board ethics approval, tribal council approval, and written informed consent from each participant. Each participant received $50 for each online survey they completed at the pretest, posttest, 6-month, 9-month, and 12-month follow-ups. Funds were distributed via a ClinCard (i.e., reloadable debit card) and could be used as cash or credit. Participants completed the surveys online using REDCap electronic data capture tools hosted by Tulane University. We sent participants individualized survey links to their email addresses and offered assistance in completing surveys by having items read to them by a research team member. We sent participants email, text message, and phone reminders for survey completion. Measures We used the following measures to assess key behavioral and psychological outcomes: (a) Dysfunctional Attitudes Scale Short Form (DAS-SF; D’Alessandro & Burton, 2006 ); (b) The primary care PTSD screen (PC-PTSD; Prins et al., 2003 ); (c) Generalized Anxiety Disorder Scale (GAD; Spitzer et al., 2006 ); and (d) Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001 ). Among these measures, we only used the DAS-SF for the adolescent sample as the other measures were developed for adults. Table 2 lists the details of the measures, including the number of items and examples of the items. Table 2. Table of Measures Name # Items Purpose Examples of Items Response Type Scoring DAS-SF e 9 Dysfunctional attitudes thought to be related to stress and depression “If I don’t set the highest standards for myself, I am likely to end up a second-rate person.”; “It is best to give up your own interests in order to please other people.” Likert: 4 “ Totally agree ” to 1 “ Totally disagree .” Summed with greater scores indicating greater dysfunctional attitudes. Total scores range from 9–36. PHQ-9 b 9 Symptoms of depression “feeling down, depressed, or hopeless”; “feeling tired or having little energy”; and “trouble falling or staying asleep, or sleeping too much” 0 “ Not at all ” to 3 “ Nearly every day.” When summed, the nine scale items had a possible range of 0 to 27, and the total score corresponded to an individual’s level of depressive symptoms along a continuum scored as 0–4 = minimal , 5–9 = mild , 10–14 = moderate , 15–19 = moderately severe , and 20–27 = severe depression . PHQ-9 scores of 10 or higher indicate clinical depression, a cutoff point validated across numerous studies. GAD c 7 Symptoms and impairment related to generalized anxiety “Over the last two weeks, how often have you been bothered by the following problems: feeling nervous, anxious, or on edge; or worrying too much about different things.” 0 “ Not at all ” to 3 “ Nearly every day.” Summed with scores ranging from 0–21. (0–4 = minimal anxiety; 5–9 = mild anxiety; 10–14 = moderate anxiety; 15–21 = severe anxiety) PC-PTSD d 4 Symptoms of PTSD “frightening, horrible, or upsetting,” that they “have nightmares about it or thought about it when you did not want to” 1= “Yes”, 0 = “No” Summed with a score ranging from 1–4. Any score that is 3 or above is deemed clinically significant with the presence of PTSD being deemed “positive” Open in a new tab Note. a Dysfunctional Attitudes Scale Short Form; b Patient Health Questionnaire-9; c Generalized Anxiety Disorder Scale; d Primary Care PTSD Screen. Data Analysis After examining missing data (which there were none) and establishing the normality of the data and the homogeneity in the variance, we generated descriptive statistics for the sample, which included baseline estimates and estimates for each follow-up wave (i.e., pretest, posttest, and 6-, 9-, and 12- month postintervention). We then used repeated measures regressions with nonparametric generalized estimating equations (GEE) to examine significant changes across these waves. An advantage of GEE is that, unlike common statistical methods in longitudinal analysis, it does not assume independence of observations, in that measures from the same person and family are usually more similar than those across units, which can lead to biased estimates ( Schober & Vetter, 2018 ). GEE can estimate the expected mean for variables while accounting for repeated measures from the same participants across time ( Schober & Vetter, 2018 ). Given the nonparametric nature of data, GEE was preferred over other methods, such as generalized linear mixed effects model. We accounted, both for repeated responses in participants’ longitudinal data while also clustering in the family unit ( Schober & Vetter, 2018 ) through the use of multiple repeated statements with SAS’s GEE procedure in Proc Genmod. Repeated measures included five waves of data from pretest, posttest (i.e., immediately after the intervention), 6-month postintervention, 9-month postintervention, and 12-month postintervention for the majority of outcomes (referred to as primary measures in Table 4 in results). Some outcomes were only available for three waves—pretest, posttest, and 12-month postintervention—and these were referred to as secondary measures (see Table 4 ). The socioeconomic homogeneity in the sample limited the need to control for confounding factors; however, we examined the potential confounding factors of sex and education. Moreover, we examined effect modification by sex, including an interaction term between sex and the given survey timepoint evaluated. Table 4. Changes in Dysfunctional Attitudes, Generalized Anxiety, Depression, and PTSD After WHF Program Crude Models Adjusted Models a Timepoints b Beta Estimate (S.E) for time/wave Z (p-value) Beta Estimate (S.E) for time/wave Z (p-value) Dysfunctional Attitudes −0.88 (0.34) −2.55 (0.01) −1.15 (0.26) −0.44 (<0.01) Primary Depression −0.96 (0.43) −2.24 (0.02) −0.97 (0.43) −2.25 (0.02) Secondary Anxiety −0.87 (0.34) −2.60 (0.01) −0.86 (0.33) −2.61 (<0.01) Secondary PTSD −0. 18 (0.06) −3.00 (<0.01) −0.16 (0.05) −3.04 (<0.01) Secondary Open in a new tab Note. a Adjusted for sex. b Primary measures are asked at pretest, posttest, and 6-, 9-, and 12-month postintervention. Secondary measures are asked at pretest, posttest, and 12-month postintervention. Results Table 3 displays the means and standard deviations of focal outcomes across each wave of data collection (i.e., pretest, posttest, and 6-, 9-, and 12-month follow-ups) by sex. In all cases, reductions across outcomes were greater for males than females. Table 3. Means By Outcome, Event, Sex, and Age Event PRE POST 6 Month 9 Month 12 Month Variable Sex Mean SD Mean SD Mean SD Mean SD Mean SD Dysfunctional Attitudes( n = 24) Male 35.40 11.64 28.80 10.48 32.10 10.43 37.20 3.65 28.00 11.21 Female 35.85 12.63 32.38 9.46 32.15 10.39 36.50 10.68 32.08 8.88 Total 35.65 11.94 30.83 9.85 32.13 10.17 36.82 8.10 30.30 9.93 Alcohol Use ( n = 12) Male 8.80 12.99 5.60 8.32 5.20 4.97 4.40 4.62 4.80 4.55 Female 4.56 6.21 2.11 3.33 1.78 2.28 4.13 6.13 2.89 4.11 Total 6.07 8.95 3.36 5.58 3.00 3.70 4.23 5.39 3.57 4.20 Anxiety ( n = 12) Male 3.60 3.78 2.00 2.83 .40 .55 Female 5.33 7.25 4.67 5.50 3.00 4.66 Total 4.71 6.12 3.71 4.78 2.07 3.89 Depression ( n = 12) Male 7.40 7.33 2.20 2.59 1.20 1.64 Female 6.67 8.77 3.00 4.27 3.44 4.80 Total 6.93 8.00 2.71 3.67 2.64 4.03 PTSD ( n = 12) Male 1.80 1.79 .40 .89 .40 .89 Female .67 .87 .56 1.13 .56 1.33 Total 1.07 1.33 .50 1.02 .50 1.16 Open in a new tab Note. Numbers displayed are Mean (Standard Deviation). As shown in Table 4 , we observed significant declines in dysfunctional attitudes ( B = −0.88, p = 0.01), along with significant declines in symptoms of depression ( B = −0.96, p = 0.02), anxiety ( B = −0.87, p = 0.01), and PTSD ( B = −0.18, p < 0.01). These decreases over time held, and with exception of PTSD strengthened, even after controlling for sex. Postintervention changed demonstrated greater declines for males than females in dysfunctional attitudes ( B = −1.15, p < 0.01), along with significant declines in symptoms of depression ( B = −0.97, p = 0.02), anxiety ( B = −0.86, p < 0.01), and PTSD ( B = −0.16, p < 0.01) as shown in Table 4 . Sex differences were observed, with significant two-way interaction terms, for dysfunctional attitudes ( B = −0.57, p = 0.04) and symptoms of anxiety ( B = −1.87, p = 0.03), depression ( B = −0.14, p < 0.01), and PTSD ( B = −1.68, p < 0.01), with a greater decline in scores for men compared to women over time. Discussion With reductions in adolescent and adult dysfunctional attitudes associated with depression and adult symptoms of depression, anxiety, and PTSD, the results of this study demonstrate promising pathways toward enhancing wellness through the WHF program. The WHF program was developed through CBPR and targets its focal outcomes directly and indirectly through experiential and psychoeducation activities to promote skills associated with optimum mental health and wellness, including emotional regulation, resilience, culturally relevant protective factors, communication, healthy relationships, and healthy behaviors (McKinley & Theall, 2021; McKinley et al., 2019 ). Although only a small pilot study, this research study extends those findings to examine beliefs underlying depression and symptoms of depression, anxiety, and PTSD to provide a potentially culturally grounded program to prevent these conditions. Given the presence of sex differences across outcomes and in prior research (Ka’apu & Burnette, 2018), interventions should center sex and gender in interventions. Despite a small sample size promising results warrant future replication and extension. Strengths and Limitations Because the article focuses on pilot results, the analyses and results should be considered exploratory. This longitudinal study increases the precision of treatment effects and the power to detect effects, even in smaller samples ( Schober & Vetter, 2018 ). Based on prior evaluations of the original Celebrating Families! program, a sample size of between 60 to 75 families is needed to have the adequate power to detect meaningful effect sizes from the intervention ( Kumpfer et al., 2002 ). The primary limitations of this study are its sample size, limited generalizability, and its being a pretest-posttest study with no comparison group. Although all outcomes trended in the expected direction and were statistically significant–remarkable given the sample size–a larger sample is needed to assess the extent and replicability of these trends and true efficacy. Moreover, a randomized control trial or its equivalent is needed to compare whether those who receive treatment experience more optimal outcomes than those who do not receive treatment. Conclusion Results of this study reveal sex differences and promising pathways for improved health equity, wellness, and resilience. Such improvements include postintervention declines in adult and adolescent dysfunctional attitudes, and adult symptoms of depression, anxiety, and PTSD. More research and programs are needed, given the lack of available sex-specific and family focused culturally relevant interventions ( Burnette & Figley, 2016 ; Gone & Trimble, 2012 ; Ka’apu & Burnette, 2019 ; Liddell & Burnette, 2017 ; Thomas et al., 2009 ). Interventions have begun to approach wellness holistically in culturally relevant ways ( Dickerson et al., 2020 ; Schultz et al., 2016 ; Kelley & Lowe, 2018 ). Promising interventions center experiential activities and Indigenous worldviews in wellness and mental health promotion ( Schultz et al., 2016 ). Examples of approaches include those of Schultz et al. (2016) have integrated gender focused programs focusing on Indigenous women who walk their ancestors’ path of removal to reconnect and re-envision original teachings for wellness in spiritual, physical, environmental, social, and psychological health ( Schultz et al., 2016 ). The WHF program follows Sam et al. (2022) approach to mental health promotion that centered wellness, harmony, the medicine wheel, teachings of a sacred tree, smudging, family, culture, and reclaiming Indigenous worldviews (Same et al., 2022). WHF program integrates Indigenous knowledge and spirituality with family-based healing and talking circles to model culturally relevant communication, smudging as a culturally ground form of prayer, and the medicine wheel approach to wellness (McKinley & Theall, 2021). Talking circles are culturally congruent and have been used in after-school programs with youth with promising promotive pathways for wellness and mental health ( Lowe et al., 2022 ), including increased cultural knowledge and identity, family support, and community support ( Kelley & Lowe, 2018 ; Lowe et al., 2022 ). The talking circle intervention found significant declines in Indigenous (18–24-year old’s) behavioral health problems, substance misuse, depression, and cumulative trauma ( Lowe et al., 2022 ). Same et al., (2022) centered Indigenous worldviews to understand needs and preferences of adolescent eMental health apps (mobile health applications) with ancient practices of storytelling to integrate holistic approaches to wellness, as indicated, “Indigenous storytelling promotes the balance of intellectual, physical, emotional, and spiritual traditions for a healthy lifestyle.” ( Sam et al., 2022 , p. 4). Collective storytelling and the Two-Eyed Seeing combine Indigenous and Western approaches and youth engagement in program development health ( Sam et al., 2022 ). Culturally grounded interventions are recommended (See Dickerson et al., 2020 ) for work with Indigenous peoples in culturally grounded, ethical, and evidenced informed ways. Not only are culturally grounded interventions important to prevent harm ( Griner & Smith, 2006 ; Whitbeck et al., 2012), but public health researchers have also argued for decades that effective behavioral health interventions must be culturally grounded in the local context and values to work ( Barrera et al., 2013 ; Resinicow et al., 1999 ). Griner and Smith (2006) conducted a meta-analysis of 76 studies on culturally adapted interventions and found interventions targeted to specific cultural groups were four times more effective than nontargeted interventions; culturally tailored interventions reported a moderately strong weighted effect size of .45. Culturally grounded interventions not only minimize spontaneous adaptations, which undermine fidelity and efficacy ( Marsiglia & Booth, 2015 ), but also increase the engagement and retention of underserved communities, leading to sustainable behavioral health improvements ( Kumpfer et al., 2002 ; Marsiglia & Booth, 2015 ). Promising prevention programs increasingly incorporate cultural practices, and tailor programs for urban, rural, and reservation communities ( D’Amico et al., 2020 ; Dickerson et al., 2021 , 2022 ; Lowe et al., 2022 ). Situating mental health and wellness within sociostructural determinants and Indigenous worldviews is crucial (Autho(s), 2021; Wexler & Gone, 2012 ). Acknowledgements The authors thank the dedicated work and participation of the tribes and collaborators who contributed to this work. We thank Jennifer Lilly, Jessica Liddell, Hannah Knipp, Jennifer Martin, Tamela Solomon, Nikki Comby, the late Harold “Doc” Comby, Patricia Haynes, Kathleen Ferris, Juannina Mingo, Dan Isaac, Clarissa Stewart, Mariah Lewis, and Jeremy Chickaway for their incredible commitment, time and energy devoted to the Weaving Healthy Families (WHF) Program. We also thank Dana Kingfisher, Emily Matt Salois, d’Shane Barnett, and all the staff at the All Nations Health Center in Missoula, Montana for their important contributions to the pilot program. We thank Charles R. Figley, Karina Walters, James Allen, Leia Saltzman, and Tonette Krousel-Wood for their support and mentorship for this pilot program. We thank the National Association for Children of Addiction for the original program on which the WHF program was based, and White Bison for introducing its cultural components. Primary Funding This work was supported by the Fahs-Beck Fund for Research and Experimentation Faculty Grant Program [grant number #552745]; The Silberman Fund Faculty Grant Program [grant #552781]; the Newcomb College Institute Faculty Grant at Tulane University; University Senate Committee on Research Grant Program at Tulane University; the Global South Research Grant through the New Orleans Center for the Gulf South at Tulane University; The Center for Public Service at Tulane University; Office of Research Bridge Funding Program support at Tulane University; and the Carol Lavin Bernick Research Grant at Tulane University. This work was also supported, in part, by Award K12HD043451 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Krousel-Wood-PI; Catherine McKinley (Formerly Burnette)-Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholar); and by U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center. Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028201. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Footnotes Clinical Trial Registration Details The Weaving Healthy Families Program to Promote Wellness and Resilience and Prevent Alcohol and Other Drug Abuse and Violence ( NCT03924167 ). Declarations of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Contributor Information Catherine E. O’Connor, Professor, Tulane University School of Social Work, 127 Elk Place, New Orleans, LA 70112. Katherine P. Theall, Professor, Tulane University School of Public Health. References American Association of Suicidology. (2009). Some facts about suicide and depression. https://www.cga.ct.gov/asaferconnecticut/tmy/0129/Some%20Facts%20About%20Suicide%20and%20Depression%20-%20Article.pdf [ Google Scholar ] Barrera M Jr., Castro FG, Strycker LA, & Toobert DJ (2013). Cultural adaptations of behavioral health interventions: A progress report. 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