Traditional games in mental health: Healing historical trauma through occupational engagement

The profession of occupational therapy is deeply rooted in occupational justice, the belief that all human beings have an innate right to engage in meaningful, health promoting occupations regardless of age, ability, gender, social class, or other differences (American Occupational Therapy Association, 2020). Currently, more than 5 million Native Americans (NAs) live in the United States (Sanchez-Rivera et al., 2023). Occupational therapy practitioners must understand and incorporate the culture of those with whom they serve.  

This article highlights how occupational therapy faculty and students from one program partnered with staff from an adolescent residential treatment facility to obtain a traditional games training certification. The training promoted culturally relevant occupational therapy and mental health services for NA youths.  

Background and Significance  

NAs experience the largest mental health, substance use, and physical health disparities of any racial and ethnic group in the United States (Centers for Disease Control and Prevention [CDC], 2021). Gorzig and colleagues (2022) corroborated the disparities by identifying that NA men and women die 11 and 13 years earlier, respectively, than their White peers. Abundant literature has been published studying the negative effects of historical trauma (HT) within the NA population; however, current research has provided few viable solutions for recovery and healing (Gameon & Skewes, 2019). Historical trauma is defined by Brave Heart and DeBruyn (1998) as cumulative emotional and psychological distress that affects marginalized populations spanning generations. Consequently, NAs experience systemic intergenerational grief resulting from the loss of lives, lands, culture, ongoing racism, and microaggressions (Brave Heart & DeBruyn, 1998; LoneTree, 2021).  

Passage of the Civilization Fund Act in 1819 by the U.S. Congress created the legal infrastructure for the government-run NA boarding school system that operated from 1860 until 1978 (Mejia, n.d.). The schools, which housed an estimated 60,000 children, separated those children from their families and culture. The generational effects of colonialization, longitudinal racism, and resulting HT are, to this day, evident in the lives of NA children (Paradies, 2016).  

The CDC (2024) stated that children ages 0 to 17 who experience or witness neglect, abuse, or trauma are vulnerable to adverse childhood experiences (ACEs) and the associated health disparities. Exposure to ACEs often leads to an increase in morbidity and mortality rates resulting from elevated rates of substance abuse, depression, domestic violence, and suicide attempts (CDC, n.d.). Racial and ethnic minority groups, including NA adolescents, are at greater risk for experiencing four or more ACEs during their childhood. Individuals who have been exposed to ACEs may experience a decrease in participation in meaningful occupations because of generalized fear of their environment and a catastrophized sense of failure. NAs constitute the smallest minoritized group in the United States, yet they face the most health challenges partly because of HT, exposure to ACEs, and occupational injustices experienced throughout generations (Brave Heart & DeBruyn, 1998). These disparities illustrate the imperative need to advocate for culturally competent health care interventions for the NA population.  

Community-Based Collaborative Partnership 

In 2021, the Rocky Mountain College (RMC) Occupational Therapy Doctorate program partnered with Yellowstone Boys and Girls Ranch (YBGR), a psychiatric residential treatment facility (PRTF), to launch an occupational therapy clinic that serves youth ages 11 to 18 years. For decades, YBGR’s census has included clients from NA populations primarily located in Montana and Alaska. 

The current study consisted of a quasi-experimental convergent mixed methods design. The purpose of the study was to provide high-risk NA youths residing in a PRTF with the opportunity to engage in culturally relevant, meaningful occupations both while at the PRTF and post-discharge. Ten NA youth ages 12 to 17 participated in a 6-week, occupation-based group led by student researchers and the research adviser, who also provides occupational therapy services at the PRTF. Researchers received human subject approval from the institutional review board, grant funding from the National Institutes of Health (NIH) and IDeA Networks of Biomedical Research Excellence (INBRE*), informed consent from the director of the PRTF, and informed assent from the participants before initiating the study. 

The effects of occupational engagement were measured via a mixed methods approach and pre- and posttest assessments. Because of the small sample size, descriptive statistics were used and indicated a trend toward significance regarding occupational engagement, and improved autonomy and self-confidence of participants. The qualitative data analysis strongly supported the likelihood that participants would generalize engagement in healthy occupations post-discharge. Three cycles of Montana INBRE grants have funded YBGR’s occupational therapy clinic and associated RMC occupational therapy research projects.  

Participatory action research, a qualitative research methodology, was used during the study (MacDonald, 2012). The focus of this methodology is to examine interventions promoting social change through equitable and collaborative work between researchers and community members. To mitigate the risk with this vulnerable population, each iteration of the study included a community partner with lived experience as a tribal member. The community partner for this study also obtained a Level I certification from the International Traditional Games Society (ITGS). Since 1997, the ITGS has been dedicated to recovering the tribal-specific historic games that currently are disappearing from urban and rural NA communities (International Traditional Games Society [ITGS], n.d.). 

Incorporating crafting game pieces into the training, the ITGS trainers provided a variety of materials, including buffalo hair, feathers, and leather binding. Additionally, the researchers harvested approximately 100, 10-foot willow branches for the construction of various sized hoops, stakes, and spears. The process of harvesting the willow branches was intentional and required researchers to cut the branches at an angle, limit the branches harvested from each tree, and leave an offering of tobacco to thank Mother Earth for providing the gift of the willows. The objective of this exercise was to prepare participants with a holistic sense of respect, spiritual connection, and practical use of the land.  

The researchers and occupational therapist at YBGR incorporated the games and cultural traditions taught during the training into group-based occupational therapy sessions. Trauma-informed treatment approaches are required with all youths receiving occupational therapy services at YBGR because more than 90% of them have a complex trauma diagnosis. Principles of trauma-informed care and how those principles were incorporated into the group-based occupational therapy sessions are shown in Table 1. 

Table 1. Trauma-Informed Culturally Responsive Treatment 

Note. TIC = trauma-informed care; IRB = institutional review board; NA = Native American; YBGR = Yellowstone Boys and Girls Ranch. 

Clinical Implications 

The findings of the research study highlighted the positive effect of cultural activities on the mental health of NA adolescents within a PRTF. Notably, 50% of the participants explicitly noted positive changes in their mental health, providing evidence of the potential therapeutic benefits of engaging in cultural interventions. Of the participants, 70% stated that they planned to teach the traditional games they learned during the intervention to their family members or friends. 

The researchers and students identified the vital role played by community partnerships, particularly with individuals possessing lived experience within the NA community. Collaborating with a community partner facilitated the breakdown of cultural barriers and significantly enhanced rapport and trust between researchers and participants. This finding resonates with the broader literature on community-engaged research, which emphasizes the transformative effects of authentic partnerships in promoting cultural sensitivity and facilitating participant engagement. Although our study provided valuable insights into the positive outcomes associated with such partnerships, further research is warranted to deepen our understanding of the nuances and dynamics involved in community involvement.  

Conclusion 

Seeking NA culture and educational training and certification opportunities is important when providing occupational therapy services to this population. The Indigenous boarding schools were developed with the intention to eliminate NA traditions and culture. Incorporating the teachings and culture of Indigenous Peoples into occupational treatment is a powerful way to promote the value of their heritage. ITGS training equipped the researchers with applicable NA philosophies of gratitude for all that Mother Earth provides, respect for each member of the tribe, a desire to support those who are in need, and preservation of resources. Occupational therapy practitioners can incorporate culturally relevant treatment approaches if they have training, obtain a mentor with lived experience, and empower clients to share their individual culture and traditions.  

References 

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S200 

Brave Heart., M. Y. H., & DeBruyn, L. M. (1998). The American Indian holocaust: Healing historical unresolved grief. American Indian and Alaska Native Mental Health Research, 8(2), 56–78. https://doi.org/10.5820/AIAN.0802.1998.60 

Centers for Disease Control and Prevention. (2021). About underlying cause of death, 1999–2020. CDC WONDER. https://wonder.cdc.gov/ucd-icd10.html 

Centers for Disease Control and Prevention. (2024, October 8). Quick facts and stats. Adverse Childhood Experiences (ACEs). https://www.cdc.gov/aces/about/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/aces/fastfact.html#cdc_behavioral_basics_quick-quick-facts-and-stats   

Civilization Fund Act, Pub. L. No. 15-85, 3 Stat. 516b (1819). 

Gameon, J. A., & Skewes, M. C. (2019). A systematic review of trauma interventions in native communities. American Journal of Community Psychology, 65, 223–241. https://doi.org/10.1002/ajcp.12396  

Gorzig, M. M., Feir, D., Akee, R., Myers, S. L., Navid, M., Tiede, K., & Matzke, O. (2022). Native American age at death in the USA. Journal of Economics, Race, and Policy, 5, 194–209. https://doi.org/10.1007/s41996-021-00095-0  

International Traditional Games Society. (n.d.). Program Webpage. https://www.traditionalnativegames.org 

LoneTree, H. M. (2021, November 24). Healing from the trauma of federal residential Indian boarding schools. Administration for Children & Families. https://www.acf.hhs.gov/blog/2021/11/healing-trauma-federal-residential-indian-boarding-schools 

MacDonald, C. (2012). Understanding participatory action research: A qualitative research methodology option. Canadian Journal of Action Research, 13(2), 34–50. https://doi.org/10.33524/cjar.v13i2.37  

Mejia, M. (n.d.). The U.S. history of Native American boarding schools. The Indigenous Foundation. https://www.theindigenousfoundation.org/articles/us-residential-schools 

Paradies, Y. (2016). Colonisation, racism and indigenous health. Journal of Population Research, 33, 83–96. https://doi.org/10.1007/s12546-016-9159-y  

Sanchez-Rivera, A., Jacobs, P., & Spence, C. (2023, October 3). A look at the largest American Indian and Alaska Native tribes and villages in the nation, tribal areas and states. United States Census Bureau. https://www.census.gov/library/stories/2023/10/2020-census-dhc-a-aian-population.html 

Twylla Kirchen, PhD, OTR/L, is the Hybrid Director of the Occupational Therapy Doctorate Program at the Medical University of South Carolina. She served as the Principal Investigator for the INBRE grant that funded this training and project. 

Taylor Clark, OTD, OTR/L, is the Director of the OT Clinic at Yellowstone Boys and Girls Ranch. She is a graduate of the Rocky Mountain College OTD Program and served as the Co-Principal Investigator for the INBRE grant that funded this training and project. 

Kristin Mayer, Eva Donnelson, Eden Gramm, Saydee Miller, Jennifer Mitchell, and Taylor Peterson were OTS Research Students at the Rocky Mountain College OTD Program. 

For more information about obtaining cultural-based training from the International Traditional Games Society, email games@traditionalnativegames.org 

*INBRE is funded by the National Institute of General Medical Sciences division of NIH under Award Number P20GM103474.