Office for Disparities Research and Workforce Diversity Webinar Series: Cultural Strengths as Protection: Multimodal Findings Using a Community-Engaged Process

Transcript

DAWN MORALES: Welcome, everyone. You are entering the Zoom meeting for the National Institute of Mental Health webinar titled Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process. We'll be waiting for all of our registrants to enter this space, and we'll begin very soon.

Welcome, everyone, to the National Institute of Mental Health webinar on Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process. We are waiting for all the registrants to enter, and we'll begin shortly.

Welcome, everyone, to the National Institute of Mental Health webinar, Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process. I see we are at about 120, but we are rapidly adding registrants, and we will wait until more people have had a chance to join to begin.

Welcome, everyone, to the National Institute of Mental Health webinar. We are still adding participants every few seconds. I will give everybody a chance to get in and then we will begin our webinar titled Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process.

Welcome, everyone, to the National Institute of Mental Health. I see we're still adding a few participants, but it's beginning to taper off. So, I think we can begin in‑‑ we'll give everybody just one more minute to join.

Well, shall we begin? Welcome, everyone, to the National Institute of Mental Health webinar series. The NIMH's Office for Disparities Research and Workforce Diversity presents our webinar today titled Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process. The webinar today will feature Dr. Evan White, but first let me invite the acting deputy director of the National Institute of Mental Health, Dr. Sue Koester, to give her opening remarks.

SUE KOESTER: Thank you, Dawn, and hello, everyone. It is my privilege to start off today's webinar. Today, Dr. White will present multimodal data consistent with a candidate mechanism of action for the protective effects of culture on mental health in American Indian people. The research itself is timely and addresses a critical mental health disparity. In addition, we'll also learn about the process by which Dr. White has developed his innovative program of research using community‑engaged research processes.

After we hear from Dr. White, we'll hear from two members of the community advisory board working on the research project with Dr. White and his colleagues, both Chief Benjamin Barnes of the Shawnee Tribe and Chief Communications Officer Maggie Boyett. In this way, we'll not just learn about the results of the research but also the processes by which research results can be obtained to ensure they are useful and respectful to the communities they're intended to support.

And now I'll turn to my NIMH colleague, Dr. Dawn Morales, to start the webinar.

DAWN MORALES: Thank you, Dr. Koester. Our speaker today is
Dr. Evan White, who is principal investigator and director of Native American Research and the Electroencephalography Core at the Laureate Institute for Brain Research and associate professor at the Oxley College of Health and Natural Sciences at the University of Tulsa.His talk today is titled Cultural Strengths as Protection: Multimodal Findings Using a community‑Engaged Process.

Closed captioning is available for this webinar. Please submit your questions at any time throughout the webinar via the Q&A button. Questions will be posed for you verbally during the Q&A session of the webinar.If you do have technical difficulties, please make a note of the email address on the slide or note them in the Q&A box and we will work to help solve the problem. Following the data presentation, Dr. White will introduce two members of the community advisory board for the research project who will serve as discussants for this webinar.After that discussion, Dr. Sarah Morris and I will ask questions posed by the webinar attendees through the Q&A button on the screen.

I see that Dr. White's slides are all ready to go. So, Dr. White, welcome to the National Institute of Mental Health and thank you for accepting this invitation to speak.

EVAN WHITE: Thank you for that introduction, and I appreciate the invitation and I'm gonna get underway here.

So as was introduced, I'm Evan White and I worked closely with some of the members of the Shawnee Tribe on an ongoing project and I'm excited to share the details of some of that work with you today. And before we get into that, I'm going to give some background information on the formative work that I've done here that's led up to that process and then introduce the ongoing research that we're doing, which will lead into the discussion.

But prior to getting into the research, I'd like to give the acknowledgements up front.Oftentimes in these settings I feel like we run out of time and the folks that have been integral in creating the process don't get their due moment in the sun. So even though I'm the one talking today, there's a lot of folks that have benefited this work and served to make it possible. That includes our funding sources here and also the variety of training programs and institutions that I've had the benefit of training and mentorship as a part of, which I listed as well.

I'd also like to call attention to some of my collaborators and also lab members.So, you'll see work featured throughout this talk that involves collaborators across institutions, and then also some of the staff that I've identified here on the screen have been integral to some of the data that I'll be presenting today. And of course, the community partners in some of the work that we're presenting here‑‑ of course the Shawnee Tribe‑‑ and then the formative work I will be presenting comes from published work in collaboration with partners at the Cherokee Nation.

Before diving into the work that we're doing, I'd like to set the stage with a bit of context. So, it's long been noted in mental health literature that there's a disproportionate burden of mental health conditions in American Indian populations. And you'll note that there may be different collective terminology used, whether it's American Indian or indigenous or First Nations or Native American, but my use of the term American Indian is intentional.Based on my experiences here in Oklahoma and working in the communities where I work, colloquial use of the term Indian and American Indian is common and it's been expressed to me by individuals close to me and elders that I respect that if they weren't viewing themselves as an Indian, they weren't sure what they were.

So, in honoring that kind of colloquial understanding of the communities where I was raised and work, I use the term American Indians as my collective term primarily, but it is best practice generally to use the collective term that's preferred by the communities where you may be living or working.

So, with that bit of caveat, I'll dive back into contextualizing mental health conditions in American Indian populations. When viewed in a vacuum outside the context and environment within which these communities have lived and experienced the environments over the past couple hundred years, looking at it in a vacuum it can look as though these mental health conditions are as a result of some sort of innate vulnerability and/or disproportionate predisposition towards mental health conditions, and I feel like this view is shortsighted and under‑informed, primarily because when we start to look at the environmental factors that are associated with risks for mental health conditions, we can see that not only do we have disproportionate burden of diagnosed mental health conditions in these communities, but we also have a very high disproportionate presence of environmental risk factors that result from things like historical trauma and historical loss and cultural degradation as a result of policies around colonization and assimilation. And oftentimes when we think of historical trauma, it can be a bit ambiguous to mental health professionals to think about trauma on the scale of quote‑unquote history.

So what I like to draw attention to is a more proximal and sometimes easier to understand concept of intergenerational transmission of trauma, and if you can understand the transmission of trauma across generations within a family, you can imagine that expanding through multiple generations, that would constitute something more along the scale of quote‑unquote history that might have occurred across multiple generations or even hundreds of years in this case. And so that's the context within which we think about disproportionate burdens today in 2024 around the concerns that we have in the mental health field around deaths by suicide, substance use disorders, and related conditions like anxiety and mood disorders.

In this dynamic, one of the things that I've become particularly interested in is, what is the potential role of traditional culture in benefitting the mental health and our interventions for mental health difficulties in American Indian communities? So some of the work that I'll present and previous theoretical models, as the one shown here, suggest that cultural factors, whether this is engagement with traditional culture, or what we refer to as enculturation, or an identity with your traditional cultural group or spirituality and other traditional practices may actually serve a buffering effect against risk factors for a variety of health outcomes, as has previously been published, and this model's been around in this form for about 20years now. And in particular, I'm interested in this pathway: What is it about these cultural factors that might provide protection against some of the health conditions that seem to be most problematic in communities where I work but also most overlapping with the expertise that I have to offer my community, which are substance use disorders and mental health conditions? As my training as a clinical psychologist and expertise in psychophysiology and translational neuroscience, this is the skill set that I can bring to the community with respect to these needs and precisely these specific pathways. So not only what are the associations between these cultural factors and the mental health outcomes of interest, but how is it that these actual protections‑‑ what are the functional processes that underlie these things.

So, we have a couple of candidate processes that we've identified in previously published work, one being inhibitory control. So, this is a basic cognitive response known as response inhibition, and you can think of this as the functional components in your brain function that relate to any time you are stopping a pre‑motivated response. So, this may be the note of stopping at a red light that changes to a green light when you see an impatient driver coming across traffic decides to go in front of you and you have to inhibit your response to press the gas pedal. That involves a long behavioral cascade of lots of different things, but it starts with a cognitive recognition that we need to interrupt a pre‑potent response, as we might say.

And what we've shown is that the brain activity in the prefrontal cortex that's associated with these stops, especially when we focus in on very difficult stopping contexts‑‑ so in particular here we're interested in oxygen signals that we get from the inferior frontal gyrus and dorsolateral prefrontal cortex that have been shown to be associated with the response inhibition function. And what we see is when we categorize individuals based on their self‑reported potential risk for suicide‑‑ now, an important note here for the clinicians or people that are intimately familiar with the suicide risk literature, this is a fairly broad proxy for suicide risk that we derive from the mini semi‑structured interview and it's a rough categorization of anyone that reports any level of suicide risk as defined by the mini versus none at all, and when we create those broad categories, we see differences in the activation of the prefrontal cortex under response inhibition demands. And so even though this isn't definitive evidence in this case, it was enough to suggest to me that response inhibition may be a clinically relevant cognitive function in understanding the functional processes that underlie risk, in this case, for suicidal thinking or ideation about dying by suicide.

An additional candidate process that we were interested in is reward and loss processing. So, these are the processes within the brain that track salient outcomes in our environment.So, when we engage in a particular behavior, there's a portion of our neural circuitry that's responsible for tracking yes, that was a good thing, or no, that was a bad thing.

We might see this when we're tracking‑‑ in the experiments that we run, we use small monetary gains and losses that provide small bonuses to research participation and/or losses to those bonuses that help elicit these neural networks. And what we've shown is that when we're looking at a clinical condition like substance use disorder, the field hypothesis is that there's disruptive reward and/or loss processing that's related to an individual's risk for developing a substance use disorder and/or that the experience of a substance use disorder may impact the neural circuitry that tracks rewards and losses.

So in this particular project, what we've done is categorized individuals based on a longstanding history, if they've had a history of substance use disorder or a healthy control, and what you'll see across these graphs on the screen, from the left to right we see loss to gain or loss to wins and then the high and low is the magnitude of that reward, and specifically in this case, people could win a $5 bonus or win a $1 bonus or have no change or lose $1 or lose $5 to their bonus. So, you see the magnitude represented, from high magnitude losses all the way to high magnitude wins across three different subregions of a salience network, or a portion of the brain that tracks this sort of information.

And what we've shown here is that actually despite previously conceived notions about disruptions in reward processing, which is represented really by the right side of these graphs, where we didn't show significant differences between individuals that were suffering from substance use disorders versus healthy controls, it was really the response to high magnitude losses that showed the greatest difference. And specifically, individuals that had a history of substance use disorder showed blunted responding or decreased responding in these salience networks, suggesting that the portions of the brain that are tracking salient outcomes were less responsive to the higher magnitude losses in this experimental context relative to individuals that were reportedly healthy controls.

So, again, what we've identified are systems that in this model would fall under kind of neurobiology. These are candidate functions in the brain that may show some benefit in our understanding of the functional processes that are disrupted in various mental health conditions. And in this model there's a placement of culture, again, between specific risk factors and mental health outcomes, but why I was encouraged when I came across this model was because it was built a little bit in terms of delineating out those two arrows from the previous model, which is, okay, now we're situating neurobiology in between our experiences of this broad umbrella of culture and mental health outcome. And so, in this case, we're looking at a specific risk factor in this model related to low socioeconomic status, which may or may not be relevant to our populations.

So in true scientific fashion, I complicated the model by adding a more‑‑ a higher degree of risk factors that I feel like would encompass the original theoretical framework but also include risk factors that seem to be present in American Indian communities, based on previous public health literature and mental health literature‑‑ specifically things like trauma, both historical, intergenerational and within an individual, and this could be tracked through things like adverse childhood experiences or exposure to what we might consider a criterion, a traumatic event in psychiatry and psychology, but also stress related to things like discrimination and identity threat.

So, this is more of an expanded risk factor profile, I felt, was relevant for American Indian communities. And then, of course, adding into the cultural portion of the model specific factors related to Native American communities, including identity, spirituality, extended social networks‑‑ without reading the whole list here‑‑ and also thinking about other areas of health‑related research in American Indian communities that include things like indigenous ways of knowing, et cetera, that might be part of this collection of protective buffers and then candidate neurobiological processes that might be impacted by the interplay between risk and protective factors.

And you'll see in blue a list of specific components that we're actively tracking in our current program of research‑‑ we'll talk about some of them today; maybe not all of them‑‑ and then also, of course, the mental health outcomes that we're interested in affecting. So, this is kind of the broad framework that we're using at the current moment in time.

So, as you saw before, these candidate processes, we're really just looking at basic brain functions within American Indian populations. However, they didn't really include any of this cultural information, and that was due to the use of archival data when I first started this line of research that had representation in the sample. However, perhaps not so much in the variables available, but that's what we've been working in the last few years to correct.

And a recently published exploratory analysis showed that‑‑ focusing again on that response inhibition, indexed in a slightly different way. So, the previous data was from an fMRI experiment, which tracks blood flow around the brain and can tell us precisely in which locations of the brain this inhibitory activity is being found. I used a different technique in this experiment known as the Event‑Related Potential technique, which is less spatially precise, but it's much more temporally precise. And what that means is, blood flow as a biological process is relatively slow when we're comparing it to something like electrical brain activity.

So, this blood flow might unfold over a couple of seconds, whereas the electrical activity is happening on the order of milliseconds. So here we can actually track the output of pyramidal neurons in the cortex using the EEG signal, which tracks post‑synaptic potentials or the output of pyramidal neurons, and we know that there are specific neural signatures associated with response inhibition. And in this case, we are looking at how does self‑reported engagement with Native American spirituality relate to this basic brain function.

So, our results indicated a level of increased efficiency, particularly in individuals with anxiety disorders, and so there's a couple of pieces to track here on why this is important. So, we know that anxiety disorders are highly comorbid with things like substance use disorders and risk factors for things like depression and suicidal ideation and they're extremely common in the general population.

So, this is a really good clinical place to start in understanding dynamics between cultural factors and these mental health outcomes, because it's a broadly present struggle that's highly comorbid with some of the more pernicious mental health conditions that we're interested in. In addition to that, there's well‑established literature in anxiety that shows individuals who struggle with anxiety disorders‑‑ in this case, generalized anxiety disorder‑‑ have a well‑documented inefficiency with response inhibition. And what this means is, individuals who struggle with anxiety disorder have to dedicate more cognitive or more neural resources to inhibiting a prepotent response than an individual who's healthy.

And you may have experienced this too. When you're feeling particularly anxious or worried, you may find yourself feeling mentally taxed when you're performing routine tasks at work or at home, and you may have never been in a situation of worrying about a grant deadline or a deadline at work or an upcoming webinar and had to focus your attention and recognize that difficulty, but I certainly have, and the literature on anxiety sort of suggests this is true, and the way that we see this with respect to ERPs, or event‑related potentials, is an increased magnitude in this brain activity. And this is really important for this technique, because if you just track outcomes, like behavioral performance, let's say‑‑ and what's documented here is a stop signal task.

You could think of it like a very boring video game where you have people respond to basic stimulus on the screen and every so often you tell them to stop, and they have to not respond, and we track the brain activity associated with those stops. And what we see is that if you just track the actual ability to stop, there's no reliable differences for people with anxiety disorders relative to healthy individuals, and this is not to be‑‑ because the task is really not that demanding.However, when we look at the brain signals that you see on the screen‑‑ so this collection of waveforms is really correct and incorrect responding. So, you see the blue and black here are correct; green and red are incorrect responding. So, what we're really interested in is, what's the brain activity associated with those correct responses that show us we're actually tracking valid response inhibition, and we can compare individuals with GAD, noted here in the pink, and individuals that are healthy, noted in the dark blue; and you can see that reflected down here in the different scalp topographies of the signal.And this just shows that in our sample we're replicating a well‑founded effect in the field, that individuals with anxiety disorder show more inefficient‑‑ or more neural resources to a correct behavior than healthy individuals.

The interesting new addition to this work is over here, which suggests that at higher levels of Native American spirituality, normalized to the population‑‑ meaning we took the average rating of spirituality and centered all of the data around that, so that we know that individuals with higher than average spirituality and a diagnosis of generalized anxiety disorder show more efficient brain processing than those individuals with generalized anxiety disorder who had lower than average ratings of Native American spirituality.And importantly, in the group that didn't have a generalized anxiety disorder, there didn't seem to be a strong relationship between their level of spirituality and the efficiency that we're tracking in this experiment. So, it's important to note here that this data doesn't suggest that spirituality is protective against anxiety disorders generally. That's just not the question we were addressing here, and that's not the data that we had available. What we are suggesting is that for individuals who are struggling with anxiety disorders, spirituality may be related to the cognitive efficiency that they're able to muster, which means there could be a potentially important concept in thinking about recovery from anxiety disorders.

So this focus on cultural factors now becomes a really critical component of understanding this approach, because we have lots of literature about risk factors and how it relates to brain structure and function and how brain structure and function relates to mental health conditions and the entire array there, but what we have less of is a well‑defined set of operationally defined factors that fall under this umbrella of culture. It's a huge term, culture. It encompasses so many aspects of life, some of which are captured in this model, but we don't have solidly well‑defined and measurable constructs in this area to be able to start building out an empirical evidence base for how these factors interact between risk factors, neurobiological function, and ultimately mental health outcomes.

So, what I'm proposing in this framework is to use a concept of community‑engaged research known as community‑based participatory research in collaboration with American Indian communities, to help define what are those factors of culture and how can we operationalize them in a scientific knowledge base. And so, we have some key principles of broad CBPR listed here and then those have been adapted in previous research to be specific to American Indian communities, and I won't necessarily go through and read all of them. Some of you may be very well familiar with this model, but a couple of ones that I want to point out as particularly critical are number one and two here, which are acknowledging that there's been a history of harmful research practices done in Native American communities.

And if that seems like new information to you or you're interested in learning more, please email me. I'd be happy to send you some readings that would be beneficial in understanding that history. And then two is recognizing tribal sovereignty. I think this is particularly important for federally‑funded research, because the United States government has a government‑to‑government relationship with the governments of many‑‑ or all federally recognized tribes, which there's a whole dynamic there that's probably beyond the scope of our conversation today, but this is important because it creates interesting dynamics around governance of research processes.

And then, also, I'll make a note here about tribal diversity and recognizing that oftentimes in these conversations we're referring to indigenous people or American Indians as a monolithic collection of people and in reality, it's a highly diverse set of cultural, geographic, religious, and community‑based practices. So, you think of the vastness of the United States geography and that's only compounded in what we see in terms of cultural heterogeneity across indigenous peoples.

So what this looks like in terms of a research process is, rather than a typical kind of research, quote‑unquote, pipeline which goes from idea generation maybe through to publication or presentation and has the stopgaps along the way of IRB‑‑ developing a protocol, data collection, analysis, writing, this kind of standard process‑‑ a community‑engaged approach, particularly CBPR, involves a more cyclical process.

And I would center the idea of community perspectives here, and this includes identifying the problems and potential solutions. That conversation leads to generating research questions, and that's where us as scientists can basically enter this relationship as a partner and as somebody who brings a toolkit rather than brings the answers.

So, in the research question generation portion, we can bring our toolkit and help design projects and dissemination plans that will help us understand, okay, here's how we're gonna gather this information based on community input and, ahead of time, plan where this information is gonna go in the future.Once that's set into place, we do the standard data recruitment and collection analysis, and here's where we engage the community yet again, which is the analysis and interpretation. And in reality, there's a role for the community in each of these places, but there are particular points that I think are absolutely critical, and here, getting community input on analysis and interpretation of data is one of those components. And then at that point we execute the dissemination plan that was previously established with the community, and this would involve kind of the standard scientific outputs of course‑‑ things like papers, maybe future grant proposals, depending on what type of data we're collecting. If it's pilot data, we may be aiming to put in proposals for more comprehensive studies. It may involve webinars like today, it may involve conference presentations, but, more critically, we would think about dissemination back to community, and this could take a lot of different shapes. And there's a lot of folks that are doing highly creative work in how we get scientific information into communities where it can be impactful to the kinds of things that we want it to be, and maybe to no one's surprise, the impact factor is not really considered in a lot of those community output avenues. And by doing so, we can find ourselves right back at the beginning of community perspectives, because when you're disseminating the information that you gain, oftentimes you're generating as many questions as you were answers in the process, and in this way, research can become more of a cyclical and regenerative process.

So, I'd like to start transitioning to an illustrative example of this that we've done in our lab, and it's talking about studying cultural engagement. So again, under that umbrella of cultural engagement, how can we start to operationalize these components in a more empirical fashion, using the tools of empirical science to help illuminate different ways of getting measurements in this space. And so, this project that I'm talking about here comes from a previously approved project with the Cherokee Nation, and all of the data and things that are presented here are part of dissemination approvals, either in papers or presentation formats, within those agreements.

We also in this project have a Community and Scientific Advisory Council that meets quarterly to engage in all portions of the process, like I laid out before, and it's resulted in what we have deemed the American Indian multimedia stimulus set, which is currently an under‑review paper‑‑ or we've submitted a revised version of the manuscript. So hopefully this will be out in the scientific journal soon. And going into this, I want you all to keep in mind, as we're presenting this, the heterogeneity of cultures and the potential for representation in scientific samples across the variety of indigenous people that we aim to serve.

So, this stimulus set really consists of three different media types, and the idea is to think about how we can use tools that psychology, psychophysiology and neuroscience have been used to understand other abstract constructs, like emotion or motivation, things of that nature, to study this idea of cultural identity. And so, we've seen evidence of empirical use of video viewing, picture viewing, and audio listening. So, what we've done in partnership with our Community and Scientific Advisory Council is developed a set of stimuli, and here you see pictures on the screen that represent kind of two conditions, our cultural condition and our comparator condition.

And we went through a really rigorous development process where we had subjective ratings from our community and scientific advisory partners, from members in the lab on what's your subjective ratings of similarity between our cultural condition and a paired comparator image. And in this process, we then moved to an objective comparison, which included things like the presence of people or not, the presence of faces or not, the presence of specific gender presentations, the presence of motion or non‑motion, and then even more detailed, looking at what is the hue saturation and color value across the images and made sure that we didn't have any statistical differences in those categories across our cultural and comparator.

So, what we ended up with was a fairly rigorously defined set of 48 pictures that were culturally representative and a paired 48 pictures of comparator non‑Native American cultural information. We also then did this for music clips, where we had 12 clips. We did the subjective ratings of audio quality and things of that nature, but we also decomposed the frequency, tempo and pitch of these clips to make sure that we had objectively comparative stimuli, and then we did both the visual and auditory comparison in a set of videos; 14 in both conditions as well.And the reason we went through that level of rigorous comparison is because we wanted to be sure that if we're using these to elicit brain activity, that we can create a tight comparison. So that when we're contrasting brain activity in one condition versus the other, we can be reasonably confident that a lot of the differences are related to the cultural information in these stimuli, not some inadvertent differences in basic stimulus features.

And so far, we've collected subjective responding; so an individual's reaction to the arousal, the valence, whether or not this is a binary‑‑ is this related to your identity as a native person, yes or no, and then two visual analog scales, zero to 100percent, how much does this relate to your cultural identity as a Native American person and how typical is this for Native American people to experience. So those five questions are our subjective responding, and then we also have a small subset of individuals who completed this test during a concurrent EEG and fMRI scan.

When we look at those subjective ratings of arousal, valence, identity, and typicality, across the board, cultural information or the cultural stimuli was rated as higher than the comparator information, and then when we collapse across the various stimulus types, you can see the distributions. And the reason I think it's important to look at this personally goes back to that heterogeneity point earlier, which is, it's a lot easier to create something that's non‑native identity than something that is definitively native identity, as you can see by the distribution representations here.

One other surprising piece here is that the cultural information was skewed positively valenced, and this might seem like an odd thing to be surprised by, but it was unclear at the outset whether we would be tapping into potentially a sense of loss or a sense of positive emotion. So here it does seem to be positively related. And then when we look at some correlations with self‑reported enculturation, acculturation, spirituality, and social support, what we see is that we have broadly expected correlation relationships with those self‑reported ratings, particularly with enculturation being modestly positively correlated with these ratings and acculturation negatively related. Spirituality and social support were less definitive in terms of their relationship to the self‑reported ratings.

We do have some preliminary results here. These are unpublished and we are in preparation with these data, but they have been‑‑ the data that you're seeing here have been a part of presentations that were previously approved for dissemination. So, there's no new data here in terms of our dissemination plan.

So what we see is that in images, it seems like a reduction in activity in prefrontal cortical regions during picture viewing of cultural information versus non‑cultural information and a different pattern of effects during audio and video viewing, which seem to be increased activity in the precuneus during audio and video, but then in videos also, maybe some ventromedial prefrontal cortical activity that seems to be increased. Again, these are cultural versus comparator contrasts, and these regions here in audio and video are generally associated with self‑referential processing and things of that nature. So, we're still working out maybe more sophisticated analyses to help model the entirety of the stimulus viewing period rather than just a rough contrast, but this is where we are in terms of analyzing this particular data.

And then in the picture viewing data, it lends itself well to what I view as kind of my bread and butter as a psychophysiological technique, which is event‑related potentials, going back again ‑‑ similar to what we did in that stop signal paradigm, this event‑related potential is what's known as the late positive potential. So, for conventions that I don't really agree with, there's a historical precedent for plotting positive down, and I think this goes back to chart paper days, whenever needles were moving and documenting these waveforms.

But in any case, what you can see from these waveforms is that the more positive activity you see in this blue what we call measurement windows have previously been associated with more motivated attention or more sustained attention, and it's been shown in the literature for a couple of decades now that this signal is very sensitive to emotional content or motivated content. So, you see larger signals when people are viewing, say, negative imagery versus positive imagery, and that's been a key marker in understanding things like anxiety and mood disorders, but what we're showing here is that the cultural information that we're presenting is also driving an increased attention deployment or sustained attention deployment in these waveforms. It was a very exciting finding for us, and that's also in preparation.

So as a brief review, essentially what we're doing here is to try to round out in that conceptual model how are we measuring and operationalizing those cultural factors, but the limitations that are important to keep in mind are‑‑ well, one, it was really hard to get Native American males to participate in the research project; so we have a high representation of females in the sample, but also this note about tribal heterogeneity.

This is important for‑‑ most people will think, oh, what about generalization here, and there's a separate concern here for heterogeneity, which is how precisely are we really indexing these cultural factors if we know there's heterogeneity across them. So, the cultural specificity is really my focus here, which is what I'm hoping to address through our community partnerships that I'm gonna talk about.

And as a note on generalizability, oftentimes I will encourage folks to read a document about reviewing grants that the NIH put out a few years ago, published by some of my heroes in the field, but without getting too sidetracked by that, they define generalizability in this case at the level of the framework. So it may not be that you could pick up the exact variables that I'm using in this project and translate it to another community to get the same effects, but you could use the exact framework that we're employing and then the method would generalize to a different cultural context here, and I think that's an important way of thinking about generalizability in this space when it comes to cultural specificity.

So, this brings us to the partnership with the Shawnee Tribe, and we've named this project ‑‑ this name was offered to us by one of our community partners and it's pronounced Kipiyecipakiciipe, which is a word meaning "coming home." And the idea here is that using traditional and cultural engagement as a potential intervention and prevention for mental health conditions is a very exciting approach and it represents a reclamation of traditional cultural practices as promoting the well‑being of people.

So, in that endeavor, what we're working to do is to define what are the factors, what are the components of traditional cultural engagement with the Shawnee Tribe specifically. So, we have identified key knowledge holders to understand what these factors are related to traditional cultural identity, and there's some nuance related to how we can do this work appropriately, which I'll save for the discussion with the tribal partners we have here in this webinar. But then also, how do we take that knowledge of these community definitions and then translate it into empirical science that we, as scientists and mental health professionals, can use to create an empirical knowledge base that's understandable by healthcare policymakers, people who develop treatments, and people who study the dynamics around mental health so that we can actually translate traditional cultural knowledge into scientific knowledge in a modern healthcare setting.

And so this project is broken up into three phases, which consists of the first phase in a single year, and we just wrapped this phase up within 2024, which is identifying the community advisory board, putting out a way that we're gonna measure traditional cultural engagement, these concepts, with the community advisory board and then a focus group of community partners that have gone through rigorous discussions around what are traditional cultural practices within the Shawnee Tribe, and more importantly, how do those factors relate to well‑being and potentially substance use.

In this case, this project is focused on substance use disorder prevention and intervention or recovery in this case. And then the phase that we're transitioning into is taking that information and building out an empirical framework for studying these factors in a translational neuroscience paradigm and then eventually moving into phase three, which is applying that empirical framework we're currently developing into a substance use population. And at each stage along the way, we're working closely with the Shawnee Tribe administration and a community advisory board to help us make sure that we're conducting this research in the most appropriate fashion and in a way that stands to have the most direct impact to the community.

So, with that, I'd like to switch over to discussion. Hopefully I've saved us plenty of time for that piece, and I think it's an appropriate time to end the slide show and just bring everyone back, if that seems like the best thing to do at this point. Hopefully I haven't put anyone to sleep yet.

All right. So transitioning to the discussion, what I'd like to do is bring in Chief Benjamin Barnes of the Shawnee Tribe and Maggie Boyett, the chief communications officer for the Shawnee Tribe, and discuss maybe what this type of research process means for the Shawnee Tribe and if you could give us a bit of background on how the Shawnee Tribe came to this point of being interested in this type of research.

So, Chief Barnes, you want to take it from there?

BENJAMIN BARNES: Yes, Evan. So, I think I should start firstby backing up a little bit, and I'm glad you explained a little bit about tribal nations.So, with tribal nations, we are one of the three sovereigns mentioned in the United States Constitution. You have the state governments, federal governments, and then the tribal nations. Tribal nation partnerships, oftentimes we can access different NOFOs, notices of funding opportunities, that we get advantaged in a lot of those situations.So, by creating partnerships, there's opportunities to participate in community‑based participants or community‑engaged scholarship, as a scholar in the humanities side.

So, there's lots of opportunities for that. We've been working within that space of community‑engaged scholarship for at least 10 years, but it was in the space of soft science and humanities, largely in the fields of like ethnohistory, archeology, anthropology, answering some of these questions that are related to sovereignty. Like we have the ability to claim certain rights in our historical spaces, and for Shawnee Tribe that's hugely important, because between 1540 and today we lived in more than 20 states historically. So, we have to interact with all these federal agencies and sometimes we have to find answers to questions that we don't know the answers to, and we have to identify those questions.

So, it was from a framework of working within those fields‑‑ I hate to use the term soft sciences‑‑ that we were starting this practice of community‑engaged scholarship. Because for us, we get contacted a lot by a lot of outside entities wanting us to work on their project; and it's always they want to work on us, they don't want to work with us. So, there's always the question of reciprocity‑‑ what is it that we gain from your project? So, we've gotten past that place, and instead of looking for projects, other people's projects, we started devising our own projects and asking our own questions, because those are the ones that are really impactful for our community.

One of the risk factors that I didn't really understand was the boarding school process and how that affected our community. You know, probably like a lot of the population in the United States, intergenerational trauma, that statement has a little bit of a woo factor for those that are not in the sciences and we don't understand how those things work, but having visited with survivors and hearing about the way those experiences shaped their lives and personalities and the ways that those kids were removed from their homes and never got to learn how to be a father, never learned how to be a mother, they came out and they learned how to be a major or they learned how to be a supervisor.

They never learned how to be a mommy, they never learned how to be a daddy.There wasn't ever around any grandparents to learn how to be a good grandparent. And for some of those kids, when they came out of boarding school, they learned how to be brutal. So those malformed survival instincts affect their personalities later and their upbringing, and that's just one consequence, not to mention the stress related, their bodies flooded with cortisol responses and anxiety, and what does that do for developmental children as they're developing, as they're starting to create babies. So, there's a lot of questions out of just that one type of risk factor.

When I first became elected chief, one of the first things I went and done is I went to a little elementary school and one of the seventh graders there asked me what my job was. And I never had anybody ask me such a smart question in such a simple term, and really the job of the tribal leader is to undo the adverse effect of our removal, and a lot of those are not just socioeconomic.

Those are also mental and physical health outcomes and why our communities are adversely affected, why we see such high proportions of alcohol and drug abuse, but there's other things that seem kind of contradictory. We also, demographically, have one of the largest percentages of teetotalers. So most native peoples‑‑ we have a very large percentage, more than any other demographic, of people that completely abstain from alcohol, and that is because of some of the traditional stuff that we do, and we celebrate as a community.

There's a belief in those communities of having to have a clear mind and clear body to participate in them, so that you can receive the fullness of that gift.And for us when we participate in ceremony, it's very hard to put these things into words, because there's just not the vocabulary for them, but I can offer some comparisons.

When we go into ceremony, there's these moments that we have, these states of being that others have experienced in such religions like Sufism or Pentecostal Christian religions, this ecstatic state, a oneness comes upon a person.And to steal a phrase from the Buddhists, their vocabulary, this ego death, that now suddenly I feel part of a larger thing and I feel connected; I feel that my community is much larger, that my being is much larger and yet smaller. So that something else was experienced by us when we do these ceremonies‑‑ not always, but often enough that it's notable and it's remarkable.And at some of these events, we have other tribal nations that participate in these same rituals or have historically. One of those tribes that had them historically was the Miami Nation. The Miami Nation has a very robust center called the Miamian Center that is reintroducing culture and language to their people at University of Miami and Ohio. And some of the young people would come to our ceremonies and they experienced that state, and we started talking about it and started talking about how we can quantify and how can we measure and how did they want that blessing to be brought back to their community, who had had that cultural expression set aside for so long.

And out of those discussions, we started talking about how folks at Northwestern, Victoria University and University of Queensland, as well as certain models like the House of Four Walls model in Māori, public health models, how they're addressing the body as an organism, an entire organism, not just trying to treat it like western medicine. Oh, you have a symptom? Let's prescribe something for the symptom and not go to the root cause and more of an osteopathic kind of way where you're treating the whole body. We encountered others doing this work, like Joanna Shadlow.

She's an Osage professor at University of Tulsa working with the pain lab. And for decades people had just lumped American Indians into the same category as African Americans and Latinos, if the way they treat pain for Natives is the same as Black and Latinos, but it was never quantified. That's just where they stuck us. It turned out the opposite was true. So, without involving communities and actually having communities and communities‑based partnerships arranged, how can you answer those real fundamental health questions?

So, for us, as we're addressing these behavioral health questions and trying to not just help our own citizens but to provide behavioral health resources to a larger community, to find a prophylaxis that we can basically prescribe to our citizens and say "Listen, this is why you need to be involved in culture and language." Because there's not just socioeconomic benefits, like they're measuring at University of Miami and Ohio with the Miamian Center, there's real health outcomes, and we see those anecdotes in our ceremonies with 90‑year‑old men doing these events all night long until dawn, staying up all night long doing these things.

And it was a chance conversation as we were getting ready for a ceremony that Dr. White and myself‑‑ he attends the same place that I do, where we worship, where we do this type of worship, that we started talking about this project and that's how this project was born, but it would've never come about without the community being primary within the conversation. You know, nothing about us without us, and so very much we have used that idea of reciprocity to start driving some of our questions. And as for the community‑based practice and the CAB that's been formed, I will let Maggie and Evan talk a little bit more about that, but that's how we got to this place.

MAGGIE BOYETT: I'll provide a little bit more context too about how the Shawnee Tribe fits into a national picture of Indian country. There's between five and six hundred tribal nations in America and we're one of three Shawnee nations, and because of our history post‑Civil War, we were incorporated into the Cherokee Nation. And so, it wasn't until the late '90s, early 2000s that the Shawnee Tribe regained its independent sovereign status when it comes to relating to the U.S. federal government.

So, it's only been in the last handful of years that the tribe has had enough of its own independent resources to be able to enter into projects like the one that we're taking on with Evan and his team at Laureate. And because of those setbacks that our people had to face and because of what Chief Barnes mentioned about how broad our tribal history is, not just spanning backwards into time but geographically‑‑ our contemporary tribal citizens live across all 50 states and some abroad‑‑ being so far‑flung and needing to quickly catch up now that we have independent resources and the means to start catching up for our people, we have to do all of these things all at once in tandem with each other.

So, our language recovery work where a small group of language volunteers would get some classes locally up and running off the ground and then there would be a setback and then another small group would have to pick it up. Now the tribe has the resources for language recovery to be a priority for the tribe. Same thing on the health and human services side. And so, with all of these things having to work in tandem, the tribe‑‑ it's kind of imperative that the tribal nations rely on experts like Evan, and we're really‑‑ I wouldn't say lucky; I think it's kind of meant to be that Evan is a Shawnee person and is enculturated.I learned a new word today.Thanks for that, Evan.

But, yeah, like Chief Barnes was saying, this research project came from our ceremonial community, and I like to think that ‑‑ the fact that the tribe has independent resources now, that we are able to have conversations at the national level and help produce groundbreaking research that is going to be very Shawnee‑specific for our community, but the framework that Evan and his team and our community advisory board are working in and helping to further develop can be taken and will eventually help other communities. It's really, really special.

If either of you have anything else you want to say about that, I think we could probably start getting into the specifics of the community advisory board and how that came to be. Do you want to talk about that, Evan?

EVAN WHITE: Well, I can definitely introduce it. I'd like to take this point and just say thank you both for providing that type of context, because I think that it's such a rich feature of the work that we're doing to have the involvement of the community, but even in the space of community‑engaged research, working within tribal nations has this added dynamic that you all have illustrated so beautifully, which is a specific history but then also specific governance considerations, like the federally recognized status that you were referring to. But in addition to those features, there are other pragmatic considerations for research that I think are related to the process of creating these partnerships and maintaining these partnerships and thinking about growing these efforts more broadly.

So what I'd like to do is kind of zoom out a little bit and basically connect the efforts of scientists interested in mental health research and the interests of communities who want to see their people thriving and healthy, and basically the common ground that we stand on is we want to see better mental health outcomes for our people, in whatever space that we're interested in.

And the way in which we go about that may have in the past looked different and required different things, and in this space where we're coming together, I feel like the pragmatics of recognizing there's a tribal nation that has its own government, its own resources, its own priorities and development that can now interact with and partner with institutions that are targeting mental health as a public health concern, using cutting‑edge research to understand the way that those problems develop and how we treat them, and we can kind of find our common ground in that space and that involves conversations about the same types of research protections that we would put in place through an Institutional Review Board in health research broadly when we're talking about what's defined as human subjects research. We put protections in place for people that participate and how that sensitive data is managed.

That consideration gets compounded a bit when we're working with tribal nations, because now these protections that we typically in, I would say, the mainstream or western approach to research‑‑ we think of these harms at the level of the individual, as the quote‑unquote sovereign over their data security.However, when we're talking about people who represent a tribal nation in their identities, now we also have to consider the sovereignty of that nation and the potential community‑level impacts and risks for data security and data safety.

So, there's another layer, again, that is removed from the ultimate goal of our work together, which is improving mental health, but in the process of getting there, we have to be cognizant of these dynamics that need to be put into place.So, for example, we have agreements with the tribe directly through the Business Council or through the Chief's Office that help set agreements for how research should be conducted and how the data should be stored and what can be shared and how the process will unfold. And as part of that, we've developed this advisory board of individuals, and I think this is important, becauseit took me a while to recognize that individuals who aren't familiar with tribes sometimes will equate a tribal government or a tribal system with the community, and the reality is, there's overlap and sometimes those things have more overlap or less, but in reality these are really different entities.

And so in working directly with the tribal government and tribal oversight, we can set in place the governance structure but then also identify from the community‑‑ the Shawnee people in this case‑‑ representatives who have been identified as having a depth of knowledge and a depth of connection and commitment to the community of Shawnee people, as a representative board that then gets some authority from the administrative structure, the Business Council or the Chief's Office.

And if I'm misstating any of these things, Chief Barnes and Maggie can clarify it for you all, but essentially now we have this representative that's identified as community members who are knowledgeable and committed to that welfare that can then help guide the process, recognizing that the dynamics may be slightly different between community members and tribal institutions, let's say.

So, I think that kind of sets the stage for the context of the community advisory board, and then, Maggie, I don't know if you want to take it from there, or Chief Barnes, in terms of how the community advisory board itself was developed or who they are and what they represent for this type of effort.

EVAN WHITE: I'll let Maggie answer that, because when I enter a room, I tend to dominate the room just because of my office. So, I've tried to stay a little clear of the CAB meetings, and so that really allows the community to be empowered to speak.

MAGGIE BOYETT: In addition to my role as the communications officer for the tribe, I'm also a member of the community advisory board and we've got about a dozen CAB members, I think, meeting quarterly. There are just unique challenges that have come up on the CAB side of things, and I know for the institutions and the tribal government involved, each entity has its own unique challenges.

I don't mean to speak on behalf of the entire community advisory board, but I've noticed that there's just a‑‑ we have a learning curve just by the nature of it being a neuroscience research project. Evan is the expert on that, and so Evan might be able to speak a little bit better to this than I can about the translation that we need to do meeting to meeting to make sure that our CAB members are tracking and we're fully understanding the information and the questions that are being asked of us.

In general, though, I think we've got‑‑ like you said, the word committed.I've noticed just that commitment deepening with each advisory board meeting that we have quarter to quarter and that sense of responsibility growing. Because this is such a novel project for us, I think we didn't really know what to expect coming in, and now that it's fully taking shape, that sense of responsibility of this isn't just gonna happen, this also needs my input.And it's been really impactful to see what‑‑ it's been impactful for me as an individual and eye‑opening to see our community engaged with each other in this way, because we're a very small community.

There are less than 5,000 Shawnee tribal citizens, and our cultural and ceremonial community is even smaller than that. So, these are folks‑‑ I can compare it to like people that I go to a really small country church with. So, it's a very small pool of people that we were selecting CAB members from, and so we all have personal relationships with each other outside of this advisory board.And so, to have to relate to each other in this new way, it's been really interesting to see how it's shaping‑‑ how we approach coming back to ceremony now, because we've been through a full year of meetings.

So, when we see each other at our ceremonial functions or at other tribes' events or just in general, it's really nice to see everybody having this project in the back of their mind. And like I said earlier that commitment, it's just so obviously there and that comes back to it being Shawnee‑specific, and so being able to recreate that commitment and that sense of ownership that the CAB has over that project, I think, is really crucial if research or institutions are gonna take this framework and replicate it elsewhere.

EVAN WHITE: Thank you, and I think now it would be good to transition to questions. So, Dr. Morales, if you want to‑‑

DAWN MORALES: Thank you so much, Chief Barnes. I so appreciate your thoughtful discussion. I want to share with you a comment from the chat. Someone has written to you, "As a ceremony person, thank you so much for this eloquent and accurate explanation, Chief Barnes," and I wanted to lend my voice to that attendee and say thank you so much for the clarity that you brought to this. And Ms. Boyett, I thought you did a really remarkable job of unpacking the structural context, the governance and the history that was provided for this research project to occur in and for the community advisory board to develop in. So, thank you very much. And Dr. White, just thank you for everything, basically.

And with that, Sarah‑‑ Dr. Morris, would you tee off the first question for our colleagues here?

SARAH MORRIS: Yes, absolutely.

Hi, everybody. I'm Sarah Morris; I'm part of the extramural staff here at NIMH. I've been monitoring the Q&A and I'm gonna try to get us through some of these questions. There's more than we can answer in the remaining time, but there's so many good questions on a variety of topics. So, I've sort of prioritized them starting with some specific questions about Dr. White's study and then some broader questions about this area of research. So, we'll see how far we get. So, in the study‑‑ one question is about, "In the study about spirituality and GAD, how was spirituality determined or measured?" And then secondly, "Do you have suggestions for cultivating spirituality in AI populations or other populations?"

EVAN WHITE: All right. Thank you for that question.

So, the first part is a really easy answer and specific, which is the way we would measure this in that particular study was using a previously established questionnaire called the Native American Spirituality Scale, the NASS.Clicking Google Scholar or something like that will get you to that development.

The article is in the PubMed library, including the items on that. As a measurement, I think it has advantages of being established, has shown some construct validity and then we have something to base it off of. However, I do feel like there's probably a broader space within that construct to explore as part of the things that we're doing in the current project.

Now, in terms of suggestions for cultivating spirituality‑‑ I was gonna say, I don't know that I'm in a position of authority on this particular concept and I'm definitely not prepared for a thorough answer in that space.So, I'll kick that one over. It sounds like, Chief, you've got something to say.

BENJAMIN BARNES: Yeah. We didn't do it on purpose, but one of the ways that we saw an increase in people participating within ceremony and culture‑‑ and this has been true at the Miamian Center too ‑‑ was through language, that making our language more widely available has brought a lot of our diaspora of people home. So that has been absolutely fantastic. It wasn't something we sought out to do, but COVID made us rethink the way we were teaching language. And so now we have ‑‑ what is it, Maggie?‑‑ 230‑some students across 20‑some states and teaching across four time zones, five or six days a week. So, we've just had a really tremendous amount of interest with people participating in that.

But what I'd like to see and what I hope that this type of empirical study can do is similar to the work that Dr. Shadlow's work has done, in that whenever patients were observed‑‑ doctors would ask the patient "how are your feet?" with native patients, but because of the uptake receptors, they weren't aware that their feet were having problems‑‑ diabetics‑‑ and so then they end up having their foot amputated. Well, rather than asking them that question, the doctor should take off their shoes, take off their socks and look at their foot, because they may not feel that problem.

So now it becomes a prophylaxis in their practice. What I would like to see come out of us is for the doctor to say, "Do you participate in ceremony? Do you have generalized anxiety disorder? You know, we have data that says that people that participate within this have a much better way to take care of their anxiety by participating with ceremony." And they don't have to go into it all, but they could just say, "You need to contact folks in your tribal nation to direct you on how to participate within this world, so that you can have some help in feeling part of a larger community which will help your GAD or other issues," as the data will bear out.That's my hope.

SARAH MORRIS: Terrific. Thank you.

One other question about Dr. White's study‑‑ one of the participants commented, "I love the focus on resilience, healing and strength embedded in this approach, which reminds me of polyvagal theory's emphasis on the social engagement system as the neural network mediating these processes. Have you considered psychophysiological measures such as heart rate variability? I just read about an indicator of autonomic resilience defined as the latency to return to heart rate variability following a stress. Makes me wonder how those signals track with fMRI and ERP." So, a question about central versus peripheral interactions.

EVAN WHITE: Yeah, absolutely. And even more precisely, really, interaction between parasympathetic and sympathetic nervous system interaction, and I will say in the current work that we're doing, most of our measurement focuses on ERP and fMRI signals. I could even say more broadly EEG, because we're doing some frequency‑based analysis there as well, but my training is actually rooted in psychophysiology, which is why I call ERP is my bread and butter, so to speak.And some of the early work I did in anxiety and mood disorders, nonspecific to culture or American Indian populations, included heart rate variability analysis rooted in polyvagal theory.

So, I'm familiar with that literature.

I haven't delved deeply into how we might integrate that specific measurement as an indicator of the balance between parasympathetic/sympathetic nervous system activation in this context, but this is exactly why I think this framework needs to be brought to the field, is because there's a variety of these sorts of knowledge bases that exist in psychophysiology relevant to mental health that I think could‑‑ I think there's a bidirectional benefit that could be had. One, operationalizing constructs that are previously overlooked in our traditional mental health and psychophysiological research and then psychophysiological research tools that can be used to understand the underlying functions that these parts of our lives interact with.

So hopefully that answers the question.

SARAH MORRIS: Terrific, thank you.

As a psychophysiologist by training, myself, I'm super impressed by the work that you're doing in developing audiovisual stimuli. That's really very important and is gonna be a terrific resource for the field. So, thank you for sharing about that.

I think we might have time for one, maybe two more questions. So, getting into some broader issues, there was a question about managing a community‑based participatory research project."How would you manage such a project when different nations have contradictory perspectives about a topic?For example, an intercultural intervention based on indigenous knowledge. How would you or how have you managed the tension and discrepancies between nations?"

EVAN WHITE: I'm gonna havea brief ‑‑

SARAH MORRIS: Anyone can feel free to jump in.

EVAN WHITE: Yeah, I'm gonna have a brief point and then kick this over to Chief, because I think essentially in terms of managing the project‑‑ it's gonna feel a little bit like a cop‑out to hear this answer, but it's really my instinct in this space, which is ultimately, if we're going to be true to this concept of nothing about us without us research‑‑ which means we're offering a level of authority over the process and outcomes of the research to the tribal nations, and in this case, sovereign nations that have government‑to‑government status with the United States‑‑ it's really not up to me.

And unfortunately, as a researcher, I'm basically re‑shifting my role in the project as somebody with a toolkit who can serve as a resource to a tribal nation in answering a question. And in terms of resolving tensions or difference in priorities or perspectives from nation to nation is really, to some degree, something that maybe they might engage with me and get my perspective as an expert in a scientific field, but the resolution of that tension is really beyond my capacity or my role as a researcher.

Chief, you want to take it from there.

BENJAMIN BARNES: Yeah, and I feel like I'm gonna be like you, Evan. I'm gonna say something that's probably gonna sound incredibly selfish, but I think Maggie, Evan and I are concerned about solving Shawnee problems. So when the Miami Nation created their language program, they didn't set out to create a framework for the Shawnees to lean on them later to get help with our language program, but just in the same way that CBPR and CES, community‑engaged scholarship, are simply frameworks, what our hope is that by solving issues for our community‑‑ using the specific data points for our community, but it's the methodology‑‑ when this work is published, others can use that framework and find their data points to suggest to them this is their entree into this type of practice. So, we're not looking to solve a problem for all of Indian country specifically at this time, but we believe that the methodology is extremely promising for all Indian country.

So, I hope that doesn't seem contradictory.

SARAH MORRIS: Yeah, so maybe we can squeeze in one more‑‑ thank you for those thoughtful responses. Maybe we can squeeze in one more question about that, which was, "Where can one find out more about community‑based participatory research best practices and methods?"

EVAN WHITE: So, there's a couple of articles that were referenced in the talk that might be good springboards. So, there's community‑based participatory research, if you Google that and an adaptation for indigenous communities, I think you'll find a Christopher and Laveaux paper from 2009 or '10, that era. I think that's a good springboard. If you've never read about it before, it's probably a decent place to start. And then there's lots of books on indigenous research methodologies that aren't necessarily specific to community‑based participatory research but have considerations for research, and I actually have some on my shelf here.

Just maybe to put in a shameless plug for Chief Barnes, I'll put his up there too‑‑ "Replanting Cultures," which is Chief Barnes' book, but there's also Linda Tuhiwai Smith's book on decolonizing methodologies.I have Margaret Kovach's book on indigenous methodologies‑‑ or indigenous research methodologies as well.So, there's multiple references at this point that could be beneficial, and if people are interested in getting into the specific details of that, my email address‑‑ I don't know if that was available here. I can drop it in the chat maybe, if everyone can see that.

BENJAMIN BARNES: And I think those of us that work within the space are all drinking from the same well. So as all of us are pretty many nerds in this room, you go back to the citations and you're gonna find the people that are the experts in this field.

SARAH MORRIS: Great. Thank you so much. I'll stop there and hand it back to Dawn.

DAWN MORALES: Indeed. Well, thank you so much, everyone.

I so appreciate this fascinating topic that we've had a chance to explore. On behalf of the National Institute of Mental Health, I thank Dr. White and his research associates for the fascinating data, and to Chief Barnes and Ms. Boyett for serving as discussants and illustrating the role of community advisory board members; to my colleagues, Dr. Koester and Dr. Morris, for assisting in today's webinar, and Jing Tran and many others for their support in creating the webinar.

The recording of the webinar will be posted online within several weeks along with the transcript and closed captioning, and the link to that will be emailed to people who registered for the webinar. Thank you.