HOUCK – In a remote hogan near the southern edge of the Navajo Nation, Wayne Wilson lights a fire, lays out eagle feathers and remembers his grandfather’s teachings.

“He would talk to me and tell me, ‘Grandson, we’re going to do things here together. We’re going to pray together. We’re going to sing together. And I need you to pay attention as much as you can, because I don’t know how things are going to change.’”

Wilson, like his grandfather before him, is a traditional Navajo healer. He uses herbs, song and ceremony to restore the mental and physical well-being of himself and others, incorporating other practices, such as acupuncture, when needed.

“It all depends on the individual,” he says.

Before embarking on this path, Wilson endured a life filled with trauma. He came from a home rife with alcohol and domestic violence, faced isolation and abuse while attending boarding schools as a boy, and had a complex relationship with alcohol himself.

“One day I’d just had enough,” he recalls. “I just got fed up.”

He made his way to the Native American Baha’i Institute, which integrates Native American spirituality with that of the Baha’i faith. The institute’s hogan, a traditional ceremonial dwelling, is where he embarked on a long journey toward finding a renewed relationship with the healing practices of old.

“Here is where my sobriety started,” Wilson says. “The medicine way started here for me.”

Today, Wilson incorporates traditional Navajo practices with those pulled from his Baha’i faith and cultures from around the country and world to heal people.

“It’s a kind of reciprocity,” he says. “What you put out, you get back.”

‘An ongoing legacy’

Researchers have long pointed to the importance of incorporating cultural practices into behavioral health care for Native Americans, but there is an ongoing struggle to ensure those services are accessible and affordable.

In past years, federal and state legislation aimed at increasing insurance coverage of mental health treatment has expanded the availability of Western services for many.

But access to culturally responsive care and traditional healing remains limited.

In the larger landscape of mental and behavioral health care, Indigenous communities face significant disparities.

Native Americans report experiencing serious psychological distress 2.5 times more than the general population, federal data show. And although overall suicide rates are similar to those of white people, there are key differences among certain age groups – with suicides among Native Americans ages 15 to 19 more than double that of white youth.

Indigenous people also are more likely to suffer from substance use disorders.

A major factor in all of this is multigenerational trauma stemming from a long legacy of colonization, genocide and oppression, as well as forced relocation from traditional lands, sterilization and assimilation.

“We need to recognize that we’re not just talking about history. We are talking about an ongoing legacy and ongoing problems,” said Hilary Weaver, a professor emeritus at the University at Buffalo who studies Indigenous identity and well-being.

Weaver, who’s a social worker and a member of the Lakota tribe, said traditional healers play a significant role in mending these lasting wounds.

“Those traditional ways have been there long before somebody came in with a psychology degree or a social work degree or a nursing degree,” she said. “And there’s a lot of value in those tribal traditions.”

Traditional healing rituals have always been a part of Indigenous culture. Whereas Western medicine focuses on curing, often through the use of medication, Indigenous healing aims to reestablish harmony and balance – more akin, experts say, to “recovering one’s wholeness.”

Practices vary among tribes, but they typically include herbal remedies and ceremonies, such as smudging or sweat lodge gatherings, to heal and maintain mental, physical and spiritual health. And spiritual health is key, along with participation not only from the individual being treated but from loved ones or other tribal members.

“With us, it’s a family affair. Pretty much all things are,” said Roland Begay, coordinator of the Office of Native Medicine at the ​​Chinle Comprehensive Health Care Facility, one of 12 Indian Health Service health care facilities on the Navajo reservation.

A traditional healer for more than 30 years, Begay has a deep understanding of its importance.

“I grew up around Native medicine. I grew up around medicine men,” Begay said. “My great-grandpa, my grandfather, my dad were all practitioners. So I was raised among that.”

Many traditional healers, including Wilson, work independently, but it’s become more common for hospitals and medical facilities to employ traditional healers.

The health center in Chinle has four traditional healers on staff to provide services and two hogans and sweat lodges for ceremonies. At a patient’s request, traditional healing can be integrated alongside Western medicine, all at no cost.

These services, Begay and other experts note, are particularly important for mental health and wellness.

In Indigenous communities, depression and other mental health conditions are more likely to be related to family, cultural and community dynamics than individual experience, meaning Western-based treatment without cultural context is often less effective.

“Somewhere, a person gets out of balance,” Begay said, “and the intent is to get him back in balance.”

One of the rare studies published on Native healers, a 1998 study in the Archives of Internal Medicine, found that more than 60% of Navajo patients surveyed had seen a traditional healer and about 40% used them regularly.

More recent studies show that Native Americans who suffer from depression or a substance use disorder are significantly more likely to seek help from traditional healers over other providers.

Avery Denny is a professor of Navajo studies at Diné College in Tsaile and president of the Diné Hataałii Association, an organization of traditional Navajo healers. He has worked in clinical settings alongside psychiatrists before, and he’s seen times where traditional healing has worked where Western medicine hasn’t.

“They’re given pills and psychiatric care, but then that same patient comes back over here and says, ‘I want a second opinion. I want to go traditional. I want to be diagnosed.’”

Like Begay, Denny says family and community are central to the process of healing.

“All the religious intolerance and human rights violations and historical trauma – and all the things that happened to our people that got us all sick – the people that have done that to us couldn’t make medicine for us,” he said.

“They didn’t know how to heal it, to heal us.”

Barriers to care

Traditional services are free to Native Americans at facilities operated by the Indian Health Service, but supply can’t always keep up with demand at the chronically underfunded federal agency.

A 2011 federal report found just 33% of 514 IHS and tribal facilities providing mental health services offered traditional healing. And many of those clinics are located on or near reservations, even though 70% of Native Americans live in urban areas.

“Almost all of those services are for reservation-based populations, and for decades, the majority of Native people have not lived on tribal territories,” said Weaver of the University at Buffalo. “So there’s a mismatch between where services are and where people are. Some Native people have private insurance and can pay for mental health care. Many others do not.”

In some states, health officials are trying to address all this.

For years, Arizona, California and other states have been asking the federal government for the OK to reimburse the cost of traditional healing services under Medicaid.

While IHS provides free health care to Native Americans, services are available only to members of federally recognized tribes and within specific geographic service areas.

With over 50% of Native Americans lacking private health insurance, Medicaid becomes another important source of care. As of 2019, federal data show, some 42% of American Indians and Alaska Natives relied on Medicaid or public health insurance coverage.

In 2015, Arizona established a workgroup to help develop parameters and potential payment methodology related to traditional healing for federal and state Medicaid officials to consider.

In a memo a year later, Arizona leaders noted that traditional healing, “while beneficial to tribal members,” has not been considered a covered Medicaid service, “despite it being promoted in the Indian Health Care Improvement Act and by IHS.”

And yet, to date, the federal government has declined to approve reimbursement.

In a letter last month from the federal Centers for Medicare & Medicaid Services to the Arizona Health Care Cost Containment System, the federal agency said it “recognizes the state’s goals of addressing disparities in the American Indian and Alaska Native community and will continue to work with the state on this request.”

CMS declined additional comment about why the change has taken so long. It so far has not approved reimbursement for traditional healing for any state. A spokesperson said the requests “are still under review.”

Heidi Capriotti, a spokeswoman for Arizona’s Medicaid agency, said federal officials “recognize our interest in traditional healing services and how important it is for our tribal communities, and have agreed to continue negotiations on this topic.”

“We don’t know a specific issue that’s holding it up, only that they like to align multiple states,” Capriotti said. “So it might be a conversation that includes more than Arizona.”

Tribal health centers, IHS facilities and clinics that are part of the Office of Urban Indian Health Programs allocate money out of their own budgets to provide the infrastructure and staff for onsite traditional healing. The financial relief that would come with allowing these services to be reimbursable through Medicaid could lead to an expansion of services, experts said.

“This has the potential to sustain them … and to maybe even increase the number of traditional providers that are in their systems,” said Kim Russell, director of the Arizona Advisory Council on Indian Health Care, which works to increase access to health programs for the 300,000 Native Americans living in Arizona.

Although the Navajo Nation has been one of several Arizona tribes pushing for this reimbursement, not all 22 of the state’s federally recognized tribes see it as in alignment with their own traditions. Russell said some abstained from the conversation.

Even approval would come with limitations. Traditional services may require additional travel by family members over long distances to attend ceremonies or gather materials that are used in practices, such as tobacco and herbs.

And for Indigenous people in urban areas like Phoenix, even if a traditional service is offered by a nearby practitioner, they may need to commute hours to wherever a particular ceremony is traditionally performed. Russell, who lives in Phoenix but grew up in Chinle, knows this all too well.

“Some of the services can only happen in our traditional dwellings,” she said. “Would I have to travel all the way back five hours north to get that service?”

Outside of Medicaid reimbursement, there have been other efforts to expand access to these services.

Alaska’s Behavioral Health Aide Program, founded in 2009 by the Alaska Native Tribal Health Consortium, trains people in the state’s rural and Indigenous communities to provide culturally appropriate behavioral health prevention, treatment and recovery services.

And in urban settings, organizations like Native American Connections in Phoenix have for decades provided access to traditional healing services in conjunction with Western mental health care.

Whether the federal government eventually OKs reimbursement for these services or not, Russell said, “Our practices will continue.”

Teaching the next generation

Wayne Wilson won’t turn down anyone who needs help, money or not. He believes payment should take the form of whatever someone can give: turquoise, tobacco, food, water.

Beyond financial barriers, one of his biggest concerns is how to ensure these practices carry on for generations to come.

He has encountered families who don’t want their children to learn traditional ceremonies because of their religious beliefs; many Indigenous people today are Christian.

Even Wilson wasn’t able to learn all he wanted to from his grandfather, and instead had to pick up knowledge from other people – and cultures – as an adult.

Now, Wilson said, none of his own children has shown an interest in learning from him.

Back in the hogan at the Baha’i Institute, he displays some of the eagle feathers he uses for healing. Many were given to him by people he has helped: One from a veteran. Another from an Aleut woman who got it from a nephew who died.

“When it comes time for me to leave,” Wilson said, “I don’t know who these items are going to go to.”

He strokes a feather as he speaks. Wilson uses this particular feather in talking circles for youth who struggle with alcohol and drugs. It once belonged to his daughter, Nesbah.

“My daughter wore this when she danced,” he said. “She was a basket dancer.”

Nesbah died of an overdose last year after a long battle with drug addiction. She was 27. Wilson shares pictures of her on Facebook, speaks about her to anyone who will listen, and carries pieces of her with him.

“She tried really hard to overcome it.”

He holds up another feather that once was hers. He’d hoped to give it back to her when she got sober.

“I’m still holding onto it, even though she’s gone. I’m still taking care of it.”

No one’s sure exactly how many traditional healers remain in the Navajo Nation, although most leaders here agree the numbers are dwindling and many young people aren’t willing to learn.

Wilson considers his own responsibility to future generations and the greater consequences, beyond the psychological, of letting go of these traditional practices. Their loss would be just one part of the slow disappearance of Navajo culture and an interruption of people’s connection with the Earth.

“We’re going to destroy ourselves. That’s a scary thought,” he said. “That’s why I’m trying to keep these ways going for the younger generation to understand.”

In Tsaile, Avery Denny is doing the same.

He sees a lack of education and the loss of Navajo language skills in the next generation as an obstacle to keeping traditional healing alive. He cited the Hózhóójí ceremony, which he referred to as “spiritual psychology,” and said that without a strong understanding of Navajo, the ceremony loses its healing effect.

People need “to have the language be fluent to understand the prayer, the story, the song,” he said, “because the oral history, the whole piece, is all healing.”

On a weekday morning at Diné College, Denny stands in front of 13 students for an introductory class on Navajo culture. The glow of a projector illuminates him. Windows frame a scenic landscape of mountains and trees.

“Diné education will heal you,” he tells his students.

He assigns them homework, including an essay they must write about themselves. He wants the next generation to know who they are and where they come from – to find personal stability and balance but also to preserve their culture.

“If nobody learns from me,” he said, “then it’s going to be gone forever.”

Skye Elmore shares many of the same concerns as Wilson and Denny. She left the Navajo reservation with her mom when she was 5. Now 25, she lives in Gilbert, east of Phoenix, and is studying to be a veterinary technician at Mesa Community College.

“My aunt, grandma and great-grandma, as well as extended family members, continue to live on the rez,” she said.

When she was 19 and struggling with depression, Elmore sought help at the Phoenix Indian Medical Center, part of IHS, and received therapy and antidepressants.

Although the hospital had traditional services available, Elmore felt she needed to be near family to really benefit from them, so she returned to the Navajo reservation for a healing ceremony.

Elmore remembers eating peyote, and the healer burning cedar. She looked into the fire and saw a dog’s face.

“It reminded me of my dogs and how much they help me work through emotions,” she said.

Today, Elmore finds peace volunteering at animal sanctuaries, such as Goats With Horns in Gilbert. She knows the names of all the goats, chickens, sheep and cows.

Although she found traditional healing more helpful for her, Elmore doesn’t want to downplay the importance of Western treatments or therapy, which she recently has considered, and acknowledges that a lot of people may need both.

“Everybody’s unique,” she said. “And if they’re really struggling, I could see how it’s beneficial to dive into both and see what works.”

Cronkite News reporter Natalie Skowlund contributed to this story.

Cronkite News is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering challenges and solutions to accessing mental health care in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania, and Texas.