Welcome to Women’s History Month. This month, we highlight a phenomenal mental health equity champion, Mary Hasbah Roessel, M.D. Dr. Roessel is a Navajo psychiatrist and a Distinguished Life Fellow of the American Psychiatric Association (APA). She shares her experience on how to infuse cultural considerations of Indigenous peoples into psychiatric treatment.

Mary Hasbah Roessel, M.D., practices at the Santa Fe Indian Health Center in Santa Fe, New Mexico. She is Navajo and grew up in the Navajo Nation with her parents and grandparents. She received her medical degree at the University of Minnesota and returned to the Southwest to complete her residency in psychiatry at the University of New Mexico. She received an APA/National Institute of Mental Health (NIMH) Fellowship during her residency and has since worked for more than 30 years with Indigenous peoples of the Southwest, Alaska, and British Columbia. She was the lead facilitator for an Indigenous cultural competency course for the APA and provided an Indigenous-focused Circle Way process for the APA Board of Trustees.

In March 2016, she presented on a panel on missing and murdered Indigenous women at the United Nations Commission on the Status of Women. She has delivered presentations on Indigenous knowledge and climate change and wrote a chapter in the book “Groundswell: Indigenous Knowledge and a Call to Action for Climate Change”, edited by her husband, Joe Neidhardt, M.D., and daughter, Nicole Neidhardt. She is the past chair of the APA Assembly Committee of Minority and Underrepresented Groups. She continues to be committed to representing diversity and belonging within the APA.

APA: You joined us as a panelist for our APA Looking Beyond webinar, “Climate Change-Driven Mental Health Inequities.” Can you briefly share why climate change is a concern for psychiatry?

Dr. Roessel: Climate change has been added as a social determinant of mental health; it impacts people who are having trouble accessing housing, water, or electricity, or in extreme situations must move their villages, particularly Indigenous peoples. Indigenous peoples and peoples who have lived on lands for centuries are very connected to their land, and that creates an emotional connection, positive mental health, and community. Enjoying that and the ability to live in nature and have that reciprocal relationship with nature is vital to mental health, particularly for Indigenous peoples. When climate change impacts such as the loss of shorelines with rising sea levels, some Indigenous villages need to relocate, and that creates a significant problem. Some people may not realize this significance if they are in a city or insulated from nature.

I have been involved with a group of psychiatrists and psychologists coming together to provide courses on the impact of climate change and how it can increase anxiety and PTSD. We are recognizing as mental health professionals that it is a significant factor that we need to bring up in interviews with our patients. Sometimes our patients don’t make those connections either, so these courses include how to bring up climate change with our patients.

“To elevate and create diversity within psychiatry we must have a very well-rounded understanding of the history of our country.” – Dr. Roessel

APA: Can you share more about your upbringing on the Navajo Nation and how that shaped your decision to pursue psychiatry and work with Indigenous communities?

Dr. Roessel: I was born on the Navajo Nation. It’s a reservation as large as Pennsylvania. Growing up, I was privileged to have both parents be at the forefront of recognizing how education can be important for the Navajo to move forward and be part of the Western world. Both my parents started schools run by Navajo people in their local communities, and they formulated their own curriculum, which included Navajo language, history, and culture. My parents realized I needed the foundation of my own Indigenous identity to be able to navigate the Western world. They taught future presidents of the Navajo Nation at Arizona State University and were the first role models to navigate successfully in Western and Indigenous systems of education. So, I had that upbringing to strive for a higher education.

I also had a grandfather who was a medicine man. He was vital in formulating my life. As a Navajo person, you have all these milestones to help become what we call a “sacred holy earth surface person.” He gave me my first coming-of-age ceremony and different ceremonies to navigate and be strong going through the culture of the medical school system. He laid my foundation within the Navajo ways of thinking while also being encouraged to go to college.

What led me to psychiatry was my parents’ friendship with Dr. Karl Menninger, a psychiatrist who helped establish The Menninger Clinic in Topeka, Kansas. He would visit my parents and grandfather. Dr. Menninger said that the Navajo were probably the first people who knew about psychotherapy and holistic healing. So, he was a mentor as well. I saw psychiatry as a holistic way of healing patients. We deal with the biopsychosocial model and spiritual aspects and now climate change, looking at how our environment affects us. As psychiatrists, I feel we are open to that and being healers in that way with our patients.

APA: Did you experience a culture clash in medical school?

Dr. Roessel: The Western world is another culture and medical school is a different culture. I always saw myself navigating between them. The medical model sees things in a linear way focusing on outcomes, research, and evidence-based practices that often don’t consider a person’s unique background or culture. That is where the clash comes up. In medical school, we did not look at our patients’ family systems, where they lived, or if they were impacted by poverty, etc. Those types of things were difficult to navigate when all aspects of the patient were not considered. 

Yet, I encountered special people in the medical school system who wanted to know more about my Navajo background. For instance, the dean of the medical school would invite me to his office and showed an interest in getting to know me and my unique and diverse background, which helped me not feel invisible. When I saw that inclusive relationships could be established in this Western model with those of us from diverse backgrounds, I began to believe there was some hope for us belonging in the medical system. We don’t always have to roll over for a 100% Western worldview; we do have something to offer. I think that is how I was able to navigate.

APA: Can you share a bit about your experience working with Indigenous communities? What is unique about their needs and treatment, and what initiatives or approaches do you believe are effective in promoting mental health equity within these communities?

Dr. Roessel: I have worked over 30 years with Indigenous peoples. I have been blessed to have a practice like that. A lot of it has been within the Indian Health Service, working with patients from Alaska to Santa Fe, and in Canada, with the First Nations peoples. What I feel has been valuable in terms of what I bring to my practice is being a role model, being someone who can understand where my Indigenous patients are coming from. I understand the resilience and historical trauma, naming it and helping patients know that this is likely what is impacting them, and we can now go through a healing process and move forward. Still, being a clinician, all these years is what I value.

When we worked up in Shiprock, we had Navajo mental health professionals serving the Navajo population. Each mental health professional could create their own niche in how they wanted to serve their patients. Some established a community clubhouse, others a school-based program. We were able to elevate and facilitate the dissemination of these Navajo therapists’ knowledge.

I received an APA/NIMH Fellowship in residency and established the Office of Native American Psychiatry at the Department of Psychiatry in New Mexico. With that, we created summer immersion programs to share what Navajo ceremonies were, discuss integrated care, and build understanding of Navajo culture. It was a way to have professional people come to our community and learn how to engage and become comfortable working with Navajo people. We went further and created a handbook, interviewing Navajo medicine people about Navajo psychology, building on how to be culturally sensitive with your patients and recognize the value of Navajo culture, language, and family systems and how we engage with nature and have a foundation of being in harmony with the natural world. I was happy to be able to always be involved and be a part of my Indigenous patients’ communities, and to be humble to what their experiences are, not always emphasize a Western-oriented model, and approach my patients where they are coming from.

APA: What recommendations do you have for psychiatrists who serve Indigenous patients regarding the role cultural considerations play in diagnosis, treatment, and overall mental health care?

Dr. Roessel: You need to approach your patients from where they come from and what they want and expect for the encounter with a psychiatrist. Obviously, there can be a disconnect when a Western model is emphasized, and when the focus is on having patients do paperwork first and not get around to why they came in. Sometimes it takes a lot for that person to get there, so the clinician needs to be aware of the cultural background of the patients they’re serving and disparities such as lack of transportation and infrastructure (like muddy roads), and poverty. Have an open heart more than anything. Approach them from where they are coming from, utilize phrases they might use, consider how they might understand their problem, and build from that.

The DSM Cultural Formulation can be a valuable framework when working with these patients. Also, have your waiting room be inviting, like having aesthetics that are Indigenous to the area, so you demonstrate respect and value for the artistic contributions of the people that you are serving. Don’t pigeonhole or stereotype; get to know them as individuals, so you don’t make assumptions or false diagnoses. Finally, get to know and understand what cultures are like. For example, the Navajo are open to sharing our knowledge and will talk about it to anyone, including non-Indigenous people. But the Pueblo people are more private and have their own cultural and spiritual systems and don’t discuss them, especially with non-Indigenous people. So, you wouldn’t probe or ask, as this could be harmful.

APA: Given your commitment to representing diversity and belonging within the APA, what specific steps do you believe are necessary for fostering an inclusive environment for psychiatrists from diverse backgrounds?

Dr. Roessel: Part of what is so important is that we have that representation in psychiatry at all levels but don’t stop there. I am on the APA Board of Trustees, and our American Indian, Alaska Native, and Native Hawaiian psychiatrists make up less than 1% of psychiatry. Why should we focus on having that representation, given we are small in numbers? Well, we were the original people of these traditional Indigenous lands. Fostering education about where we have come from as a country and the near decimation of Indigenous peoples is imperative. With Canada, they have come further along, because they are working on the truth and reconciliation process in terms of addressing their role in colonization and dispossession and trauma upon the First Nations peoples.

In institutions like the APA, we really need to have educational processes where we understand and learn the history of what happened in this country, which can be the foundation to dismantle institutional racism. We have to make reparations and make reconciliation a priority. All psychiatrists need to learn about the impact loss of language, land, and culture has had on the Indigenous peoples and the harms of trauma. The Indigenous territorial land acknowledgment that is done at each APA meeting is a beginning. I believe that to elevate and create diversity within psychiatry we must have a well-rounded understanding of our country's history. Psychiatrists with their privilege can move forward as allies and keep working on centering diverse representation and addressing disparities.

It’s a constant work in progress. We don’t stop because we know that there is so much more that we can do, like continuing to build up the pipeline, being mentors, being out in the community, and taking opportunities to share. If you’re talking to someone from an underserved or underrepresented community who wants to be a doctor, let them know it is possible. We have to open these doors; we can’t keep the doors shut. We have to have equity within our organization. I believe we need to have trainings on racism and its impact so that we recognize that this is still a real problem and racism does exist. I have faith in the APA being able to address those issues.

APA: Any final thoughts?

Dr. Roessel: It is a difficult journey to be a very small representative of the First Nations peoples of this country. But I feel that psychiatrists and the APA need to elevate our knowledge and recognize that we are still here as Indigenous people and psychiatrists, and we have a lot to contribute. This is part of what the APA continues to work on, and I value and appreciate that. We need to keep doing more, and I am happy to be involved with the leadership in the APA and to elevate my voice within the APA leadership.

By Fátima Reynolds, MPH
Senior Program Manager, Division of Diversity and Health Equity
American Psychiatric Association