FNIM Holding Hope in Our Hearts ENG
FNIM Holding Hope in Our Hearts ENG
FNIM Holding Hope in Our Hearts ENG
Submitted by:
Cultural Safety Working Group, First Nation, Inuit and
Mtis Advisory Committee of the Mental Health
Commission of Canada
This project has been made possible through funding from the Mental Health Commission of
Canada and the Building Bridges 2 Project, a Native Mental Health Association of Canada and a
Mood Disorders Society of Canada partnership. The work of the Mental Health Commission of
Canada is supported by a grant from Health Canada.
Table of Contents
Page
Acknowledgements
Executive Summary
ii
1.0
Introduction
2.0
Method
3.0
Literature Review
4.0
Analysis
5.0
Findings
6.0
7.0
12
14
16
17
19
Discussion:
21
21
22
6.3 Metaphors
27
28
Way Forward:
31
Appendices
Appendix A:
32
Appendix B:
33
Appendix C:
34
Appendix D:
35
43
Acknowledgements
In this Mental Health Commission of Canada (MHCC) Project conceived by the First Nations,
Inuit and Mtis Advisory Committee (FNIM AC), researchers were led by the voices of those
with most direct experience and knowledge of mental health and addictions services. We
gratefully acknowledge service providers, service recipients, caregivers, community mental
health advocates and family members who participated in the Western focus groups, and people
such as Doris Greyeyes (Saskatoon), Lori Idlout (Iqaluit), Arlene Hache (Yellowknife), and Gaye
Hanson (Whitehorse) who assisted in bringing these participants together.
Building Bridges is the creation of the Native Mental Health Association of Canada (NMHAC)
and the Mood Disorders Society of Canada (MDSC). Building Bridges 2 partnered with the
FNIM AC, and together they sponsored production of a Digital Video Disc (DVD),
commissioned two research papers, conducted a successful symposium, organized and managed
the focus groups and produced this background paper. We are pleased to acknowledge
contributions from members of these two non-profit associations and the First Nations & Inuit
Branch (FNIHB) of Health Canada: Dr. Brenda Restoule & Dr. Ed Connors (NMHAC); Phil
Upshall & Richard Chenier (MDSC); Kathy Langlois and Dr. Patricia Wiebe (FNIHB). We also
express our appreciation to:
Dr. Vicki Smye (UBC School of Nursing), and Dr. Barbara Everett, for their research
work;
Orca Productions for the filming and production of the DVD;
Individuals who shared their lived life experience in the DVD;
Richard Chenier and Bev Bourget for organizing and facilitating the Eastern Canada
Focus Groups;
Ellen Whiteman and Lisa Worobec for their thematic analysis of the Western data;
Members of the FNIM AC.
It has been a pleasure for us to work in tandem with Dr. Caroline Tait, Lead for the Ethical
Programming Project, a sister project to Cultural Safety, and to have the on-going support from
the MHCC staff, especially Gail MacKean, Jayne Barker, and Howard Chodos.
ALL MY RELATIONS
Bill Mussell, Margaret Terry Adler, Gaye Hanson, Dr. Jennifer White and Dr. Victoria Smye,
members of the Cultural Safety Working Group, FNIM AC
Executive Summary
Background
As part of their Building Bridges initiative, the Mood Disorders Society of Canada (MDSC)
and the Native Mental Health Association of Canada (NMHAC) collaborated with the First
Nations, Inuit and Mtis Advisory Committee (FNIM AC) to the Mental Health Commission of
Canada (MHCC) in a joint research project to understand best and promising practices that
constitute cultural safety and relational practice in the Canadian context. In 2009, they
commissioned a total of forty-one focus groups in Western and Eastern Canada, a national
symposium in Ottawa in 2010, and two research papers, one on social inclusion, the other on
cultural safety. The purpose of this report is to provide an overview of findings from the Western
focus group consultations, augmented by themes identified in the proceedings of the symposium.
The Executive Summary of the Eastern focus groups can be found in Appendix D.
Research Question
The central question underpinning this project was What will improve practice in mental health
and addiction services for all Canadians? We sought insight into this question by conducting 27
focus groups in five Western Canadian cities with people who have experienced mental health
and/or addictions services, including practitioners and recipients of services, approximately twothirds aboriginal, one-third non-aboriginal, the majority working in aboriginal-led organizations
serving aboriginal people. The focus on mainly aboriginal agencies, their staff and clients, was
an intentional decision given that aboriginal voices have seldom been privileged.
Findings
Six overlapping categories were developed to capture the emerging themes and organize research
findings: direct care; interpersonal relations; professional development; ways of knowing;
organizational context; and, policy.
1. Direct care refers to the qualities of the care provider/care recipient relationship.
As viewed by participants, the relationship needs to be accessible, inclusive of the
disabled, respectful and responsive to the uniqueness of each individual, strengths
focused, flexible, trauma-informed, acknowledging of grief, and making use of
human connection in healing.
2. Interpersonal relations refers to the range of relational networks and formal and
informal supports in which both the care provider and recipient are embedded,
including relationships with families, community members, colleagues, peers,
mentors, supervisors, other service providers and agencies. Participants emphasized
the importance of reciprocity and dialogue, support for self-care, self-awareness and
conscious growth, and the necessity for circles of support for both care provider and
care recipient.
3. Professional development refers to the informal, non-formal, and formal knowledge
and skill development received by professionals in the course of their training to
become a mental health practitioner, as well as the multiple life experiences and
cultural practices that care providers draw upon in their work. On this topic,
participants shared insights about informal, non-formal and formal
ii
Way Forward
The findings presented in this report represent practices that can be summarized as safe, ethical,
respectful, critically conscious, culturally good and socio-politically aware. When these ideas
are used as perceptual lenses they can guide practice, inform the education of practitioners, and
provide a foundation for program and policy development
iii
1.0 Introduction
As part of their Building Bridges initiative, the Mood Disorders Society of Canada (MDSC)
and the Native Mental Health Association of Canada (NMHAC) collaborated with the First
Nations Inuit and Mtis Advisory Committee (FNIM AC) to the Mental Health Commission of
Canada (MHCC) in a joint research project to understand best and promising practices that
constitute cultural safety and relational practice in the Canadian context. In 2009, they
commissioned a total of 41 focus groups in Western and Eastern Canada, a national symposium
in Ottawa in 2010, and two research papers, one on social inclusion, the other on cultural safety.
An Abstract of the Cultural Safety Lit Review can be found in Appendix B, and the Executive
Summary of the Eastern focus groups can be found in Appendix D. The themes arising from the
Ottawa symposium are captured in the Domains for Consideration section of this report.
The question central to the project was: What will improve practice in mental health and
addiction services for all Canadians? To find answers to this question we conducted 27 focus
groups in five Western Canadian cities with people who have experienced mental health and/or
addictions services, including practitioners and recipients of services, approximately two thirds of
them aboriginal, one third non-aboriginal, the majority working in aboriginal-led organizations
serving indigenous people. The inclusion of aboriginali and non- aboriginal people takes into
account our understanding that race is a social construction; we do not dichotomize
aboriginal/non-aboriginal; rather we seek to include a range of perspectives that take into
account different experiences. We see aboriginal and non-aboriginal people as heterogeneous
groups of people whose lives are shaped by class, living situations, age, etc. The focus on mainly
aboriginal agencies, their staff and clients, was a deliberate decision based on the need to
privilege a voice that has often been marginalized. It is generally accepted knowledge that
historically, health care in Canada has been dominated by the illness and health belief systems of
the dominant culture and has subsumed those of indigenous people (Smye and Brown, 2002). The
outcomes for indigenous health have been poor. By listening to people rarely consulted, situated
in contexts seldom researched, the authors attempted to document some of the interests, values,
beliefs, and principles that may hold promise for improving the health and well-being of
indigenous and non-indigenous people, as a contribution to transforming the mental health system
in ways beneficial to all Canadians.
This report describes our methodology and approach to analysis, offers a synthesis of key
concepts based on a literature review undertaken as part of the project, and presents the findings
emerging from this work. It invites discussion regarding the implications and opportunities for a
transformed mental health system in Canada.
2.0
Methods
The Western focus groups were held in Saskatoon, Winnipeg, Iqaluit, Yellowknife, and
Whitehorse in October and November 2009. A total of 147 people participated. Of these, 97
identified themselves as indigenous (22 Inuit and 75 First Nations or Mtis). One hundred and
eight participants were practitioners/service providers. Thirty nine were individuals with lived
experience of mental illness. A significant number of providers (25) reported having gone
through their own healing journey, with or without formal assistance, to evolve into service
providers themselves. Participants working for or receiving assistance from indigenous based
organizations constituted 56% of the total, those working for non-governmental organizations
made up approximately 29%, with 15% working for a government agency. A detailed
demographic of Western focus group participants can be found in Appendix A.
The facilitators longstanding relationships with key stakeholders in the communities enabled
them to draw upon existing community networks to recruit participants for the focus groups.
Participants investment of time and energy was motivated by their interest in the purpose of the
project and its potential outcomes.
Discussions began with an overview of the project context. Focus group facilitators explained that
the initiative is intended to contribute to the joint efforts of the FNIMAC within the MHCC, the
NMHAC, and the MDSC to address the question, What will improve practice in mental health
and addiction services for all Canadians? The intention was to further the understanding of
culturally safe practice in mental health and addictions.
Through a combined process of circle dialogue and storytelling, participants were invited to
reflect on their experiences with mental health and addictions services. They were asked to
consider what was working, what was not working, and what could be improved. Participant
experiences were centered and the dialogue was generative and emergent. Participants recounted
stories of success and they also spoke of challenges and limitations and ways of addressing these.
All focus groups were audio recorded and transcribed verbatim.
To augment the focus group consultations, a two-day symposium was held in Ottawa in March
2010, attended by 60 mental health practitioners, consumers, advocates and policy makers.
Participants met in large and small groups to discuss the questions:
1. What constitutes culturally safe practice and what are the conditions in which such
practice could take root/thrive/be supported?
2. Do cultural and social institutions need to be restored or reformed in any way in order to
accommodate cultural safety? If so, what changes need to be made and what is the best
way to approach this?
Proceedings were audio recorded, transcribed verbatim and key ideas incorporated into this
report.
3.0
Literature Review
A literature review entitled Cultural Safety; An Overview was carried out for this project by an
academic team. What follows is a synthesis of highlights from this paper and additional sources.
Two key terms used in the literature review are cultural safety and cultural competence. An
overview of the many contributions made by academics and practitioners to the understanding of
these terms is beyond the scope of this paper. For our purposes here, we will rely on recent work
by the Canadian Nurses Association (CNA). In a recent position statement (2010) culture is
defined as the processes that happen between individuals and groups within organizations and
society that confer meaning and significance (CNA citing Varcoe & Rodney, 2009). Cultural
competence is the application of knowledge, skills, attitudes or personal attributes required by
nurses [or other providers] to maximize respectful relationships with diverse populations of
clients and co-workers. Further, the underlying values for cultural competence are inclusivity,
respect, valuing differences, equity and commitment. (CNA referencing Aboriginal Nurses of
Canada (ANAC), Canadian Association of Schools of Nursing (CASN) & Canadian Nurses
Association (CNA), 2009; CNA, 2010a, Registered Nurses Association of Ontario (RNAO), 2007
and World Health Organization (WHO)).
CNA states further that cultural issues are intertwined with socio-economic and political issues
and as an organization expresses commitment to social justice as central to the social mandate of
nursing. Related to the concept of social equity, CNA defines cultural safety as both a process and
an outcome whose goal is to promote greater equity. It focuses on root causes of power
imbalances and inequitable social relationships in health care (ANAC, CASN &CAN, 2009;
Kirkham & Browne, 2006, as cited in Browne et al., 2009).
While cultural competence is an important concept, it can sometimes overlook systemic barriers,
which makes it inadequate to fully address health-care inequities. Cultural safety, however,
promotes greater equity in health and health care [as it addresses the] root causes of health
inequities (CNA, 2010b). As quoted by CNA: Cultural safety is a relatively new concept that
has emerged in the New Zealand nursing context. It is based on understanding power differentials
inherent in health service delivery and redressing these inequities through educational processes
(CNA, 2010).
CNA believes that the responsibility of supporting cultural competence is shared among
individual nurses [providers], employers, educators, professional associations, regulatory bodies,
unions, accrediting organizations, government and the public. The view of the authors of this
final report is that cultural safety is most likely to be achieved as an outcome by recipients of care
if investments in cultural competence occur throughout the care system from the service interface
to system wide policy levels.
CNA, with ANAC and CASN, has also provided an excellent review of the literature as it relates
to nursing education in the document Cultural Competence and Cultural Safety in First Nations,
Inuit and Mtis Nursing Education: An Integrated Review of the Literature (2009). The paper
provides an overview of the context within which cultural competency must be developed with a
look at colonization, health disparities, health inequities, diversity of First Nation, Inuit and Mtis
Peoples and historic trauma transmission. A full discussion of the complex context within which
cultural safety and cultural competency must be developed throughout the health care system is a
task beyond the scope of this paper.
This project included a literature review of selected publications entitled Supporting Mental
Wellness of First Nations, Inuit and Mtis Peoples in Canada: Cultural Safety (Smye, Browne
and Josewski, 2010). The authors note that the hope related to the work on cultural safety is that it
will enhance the ability of healthcare providers and others to deal more effectively with major
structural and relational issues and barriers facing indigenous and non-indigenous communities.
The authors see the research and analysis related to cultural safety and cultural competence as
tools to deal with identified inequities in health, education and social services.
Smye et al., (2010) provide an overview of another key idea, that of relational approaches. This
concept recognizes that peoples experiences, including health and illness experiences are
shaped by the contextual features of their lives social, historical, political, cultural and
geographic as well as other factors such as age, gender, class, ability, biology and so on
(Hartrick Doane & Varcoe, 2005, 2007, 2008). Relational approaches refer to more than
respectful, supportive, caring and compassionate relationships. Although interpersonal
connections are a central feature of excellent relational practice, this view takes into account
how capacities and socio-environmental limitations influence health and wellbeing, the illness
experience, decision-making and the ways people manage their experiences (Browne, Hartrick
Doane, Reimer, Macleod & McLellan, 2010).
One of the sections of the literature review focuses on the historical and present context of
colonization and additional impacts affecting First Nation, Inuit and Mtis mental health. The
section is summarized in this way: the mental health inequities of Aboriginal peoples cannot be
glossed over as lifestyle, behavioral or cultural issues; rather, they are manifestations of the
historical, social, political, and economic determinants (Smye et al., 2010, p. 15). The
cumulative losses in population, land and economic resources, language and cultural teachings,
self-government and self-sufficiency mortally threatened holistic health while disrupting the
ways and means through which health was taught, maintained, and restored (Mussell, Nicholls
& Adler, 1993 as cited in Smye et al., 2010).
Smye et al., (2010) identify that an important historical and contemporary tension contributes to
sustaining mental health inequities: A tension exists between Indigenous ways of understanding
and responding to mental health and illness and the current mental health system, a system
dominated by biomedical understandings. The findings were summarized in the statement that:
[m]ental health service delivery models that are designed in keeping with the dominant
biomedical views of mental health and illness, create barriers to access and often only
inadequately recognize the health care needs of Aboriginal peoples (Smye et al., 2010, p. 18), a
perspective in keeping with many other authors (e.g., Adelson, 2005; British Columbia Provincial
Health Officer, 2002; Canadian Institute for Health Information, 2004; Dion Stout, Kipling &
Stout, 2001; NAHO, 2002, 2003; Smye & Mussell, 2001). Mental health services often are not
effectual, underused and not accessed by Aboriginal peoples (Smye & Mussell, 2001). In
addition, research continues to show that tacit and sometimes overt discriminatory practices and
policies continue to marginalize many Aboriginal people in the mainstream health care system
(Browne, 2005, 2007; Brown & Fiske, 2001; Culhane, 2003; Dion Stout & Kipling, 1998; Dion
Stout et al, 2001; RCAP, 1996; Smith et al. 2009a, as cited in Smye et al., 2010).
Control over health services delivery has been a priority for First Nation communities for more
than two decades. As summarized by ONeil et al, (1999) true community healing and wellbeing can be found only through self government and self determination (as cited in Smye et al.,
2010, p.18).The Kirby report set the stage for the current work of the MHCC by supporting a
formal commitment to improving Aboriginal health; recognition of the issues; support for selfdetermination and control; fostering greater participation in design, delivery and governance of
programs; improving social determinants of health and promotion of culturally appropriate,
holistic approaches to health (Kirby, 2002, as cited in Smye et al.,2010, p.19).
Connected to the issue of Indigenous control is the issue of cultural continuity and its relationship
to individual and collective identity. Cultural discontinuity has been strongly linked to the
disproportionate problems of Aboriginal communities with depression, suicide and family
violence. (Chandler and Lalonde, 1998; RCAP, 1995, as cited in Smye et al., 2010). In contrast,
studies have found that the degree of control that First Nations communities have over civic life,
such as education, health care, child and family services, and fire and police services, was
negatively correlated with rates of suicide (Lalonde, 2005, as cited in Smye et al., 2010)
Under the conditions of colonization, Aboriginal systems of medicine were disrupted and
challenged by new forms of understanding health and illness. Traditionally, Aboriginal peoples
understand health as a holistic concept, which results from a harmonious balance or equilibrium
between different spheres of life, such as the physical, mental, spiritual and social dimensions
(Mussell et al, 1991; Smye & Mussell, 2001; Waldram, 2004, as cited in Smye et al., 2010, p.
21).
The literature review describes the findings of a review of Aboriginal best practices in mental
health. The working group that led the best practices review found that community based
initiatives and a balanced approach to mental health including treatment, prevention and health
promotion strategies have proven more effectives than treatment-oriented mainstream services
under non-Aboriginal authority (Smye & Mussell, 2001). In addition, findings from the
Aboriginal Healing Foundation (AHF) projects suggest that the necessary elements of promising
healing practices related to historical trauma (e.g. residential school abuse) include: programs that
reflect Aboriginal values; ensuring personal and cultural safety as a prerequisite to healing from
trauma; capacity to heal, i.e., the presence of skilled healers, therapists, elders and volunteers;
and, reclaiming history. Also, included in this framework are the three pillars of healing: i)
cultural interventions, ii) therapeutic healing, i.e. a combination of a broad range of traditional
and Western therapies and iii) an environment that meets the conditions that influence both the
need for healing and the success of the healing process (AHF, 2010, as cited in Smye et al. 2010,
p. 21).
The literature review also introduces the concept of ethical space. The notion of ethical space
represents a space of engagement that facilitates the development of cross-cultural approaches
that are ethically sustainable and aim to redress inequities (Ermine, 2005, 2007; Tait, 2008, as
cited in Smye et al., 2010, p. 25). In the context of ethical space, and in consideration of the moral
questions that cultural safety prompts, mental health and addictions services have the potential to
be transformed in ways that acknowledge the pain, suffering and intergenerational realities and
experiences of Aboriginal peoples resulting from colonial assaults and the resilience and
resistance of Aboriginal peoples to historic and contemporary adversity (Tait, 2008, as cited in
Smye et al., 2010, p.25). Finally, Smye et al., (2010) support a call for integrated services
meaning services that include interdisciplinary teams of skilled Elders, community outreach
workers, trauma counselors, specialists in chronic pain, residential school healing circles,
psychological services, social workers, housing services etc (p. 26).
4.0
Analysis
Analysis was undertaken by the five members of the FNIM AC cultural safety working group
(which included the two focus group facilitators). Transcripts were closely read multiple times
and emerging themes and potential framing metaphors were identified. Over the course of several
meetings, a number of high-level themes began to be generated by the team. This led to a
framework for analysis depicted in Figure 1. Specifically, six interrelated categories were
identified to capture the themes emerging from the focus group transcripts: direct care,
interpersonal relations, professional development, ways of knowing, organizational context and
policy. Each of these categories was conceptualized as existing within a defined space and as
embedded within a larger sociopolitical and historical context.
Next, each team member read a set of transcripts from one of the five cities using the framework
as a point of reference. Members then met in-person to discuss their emerging understandings and
perspectives. The group continued to meet, either in person or through teleconference, to deepen
their analysis and comprehension of the multiplicities and complexities of the data. Our findings
emerged through a process of iterative cycles of analyses, ongoing discussion and negotiations,
consultations with colleagues, collective reflection on our goals, and a return to the literature.
While participants spoke about the tensions and constraints within the field of mental health and
addictions, they also described innovative, strengths-based practices in the face of these
considerable challenges. We decided that the best way to honour the persistence, creativity and
resilience of focus group participants would be to emphasize their hopeful actions and ideas about
good cultural practices. These are described in sections 5.2 to 5.7 of the Report.
The work of our team was supported by secondary thematic analysis of the focus group data
completed by research assistants from the University of Saskatchewan. The methodology
included the use of ATLAS-TI software which was used to manually code and organize the data.
Their analysis uncovered barriers and challenges that are described in section 5.1 of the Report.
Figure 1 graphically provides one example of how the larger context that includes socio-political
and historical factors works with the natural world, land and physical environment (including
human constructed things and systems) to influence our relational and ethical engagements. The
six aspects that will be used to organize findings are captured in the over lapping segments these
are interrelated and contribute to the forces that both enable and constrain relational practice and
ethical engagement which rest in the centre of the model.
Some of these categories have been drawn from White (2007).
Figure 1
5.0
Findings
5.1
Participants identified specific barriers and challenges that must be addressed to improve
the mental health system, including service, institutional and funding barriers.
Barriers to services include general access due to geography including but not limited to rural,
remote or reserve experiences, sometimes due to a lack of transportation and/or affordable and
safe housing or shelter.
Institutional barriers are those created by the structures and processes through which mental
health and related services are delivered. Barriers and challenges identified in this category
include:
the structure of mental health and addictions services often separated from and delivered
in isolation from other health services and silo funding;
classism, racism, sexism, ableism and other forms of social and structural discrimination;
lack of continuity of care in rural and remote communities due to staff turnover and lack
of aboriginal care providers in small communities with multiple personal and
professional relationships with clients and the need for boundaries and time away from
community responsibilities;
lack of organizational supports for self-care and healthy living on the part of service
providers;
lack of support for rebuilding individual, family and community cultural identities and
connectedness;
unmet high needs related to intergenerational trauma and programs of insufficient length
and scope that fail to provide treatment of both mental health and addictions
lack of resources to meet basic needs or to fund comprehensive and culturally appropriate
mental health and addictions services;
erosion or absence of social safety net increases vulnerabilities for some clients;
no core funding all project based and short term not able to build organizational
capacity;
The remaining findings have been organized using the six aspects depicted in the model above
direct care; interpersonal relations; professional development; ways of knowing; organizational
context and policy. The categories are interrelated; many of the stories and findings arising from
the stories could have been captured in several different ways in more than one category.
5.2
Direct Care
Direct care in the context of this project refers to the qualities of the care provider/care
recipient relationship. Focus group participants expressed that direct care needs to be:
accessible (physically, emotionally, mentally, and spiritually), inclusive of the disabled,
respectful of and responsive to the uniqueness of each individual, strengths-focused,
flexible, trauma-informed, acknowledging of grief, and making use of human connection in
healing. They emphasized the interconnectedness of the physical, emotional, mental and
spiritual needs and the necessity of addressing these in their wholeness, since in the person
of the recipient of care they are always interrelated, not fragmented.
Access
Direct care should be physically accessible in terms of its location, eligibility criteria,
environment, and provision of handicapped access; emotionally accessible through assurance of
confidentiality and welcoming staff who encourage and support movement beyond fear, stigma
and discrimination; mentally by providing materials in different languages (appropriate to the
geographic area), through reading and literacy levels that match the readiness of potential clients;
and spiritually, validating of personhood, soul, and culture.
A person can walk in here and say I have this problem, could I see someone, and
that person would be accepted and told we would call them back or be seen face to
face right away if that was possible. Someone always goes to talk to them right
then. (Service Provider [SP] Whitehorse)
An accessible service is one that is well-located and designed, properly staffed by compassionate
and appropriately skilled people who are non-judgmental, have strengths-based respectful
approaches, and invest in building social supports. Staff is well networked with complementary
services and agencies (one door, many resources) with the capacity to respond to basic needs in
practical ways including provisions for food, clothing, shelter, safety.
You can talk all you want, but after the talk is done and the session is over,
theyre back on the street so you know housing is a necessity, a major issueand
if they need to have psychological help, get them that help, and if they need
detoxification, then get them into a treatment program, and if they need further
education, you know, go for it, but if theyre willing to take on a job, well then, get
them one (Service Recipient [SR], Yellowknife)
The desired service philosophy is decolonizing and humanizing, and addresses root causes, rather
than offering only a superficial fix.
We specialize in core issue therapy, rather than deal with things piece meal. We
have a program of healing that shows you where all this is coming from and
gives you the tools for living today. (SP, Saskatoon)
Inclusiveness and disability
Inclusiveness is an important feature of an accessible service. Inclusiveness means designing and
delivering services that are specific for individuals with special gifts, Fetal Alcohol Spectrum
Disorder (FASD), brain injury, and other abilities and disabilities to adequately meet their unique
needs. The price of inappropriate access for people with disabilities is underscored by the
following comment by a participant in Yellowknife.
Because of my disability background, I recognize that many of the people Ive
worked with in the correctional custody or on the streets are horribly disabled.
These are people who, if they had escaped brain damage before they were born
from whatever toxic substances they were exposed to, continue to sustain head
injury from falls, blows to the head, substance abuse or addictions issues. We take
those people and put them into correctional custody where even the guards say
they dont belong here-theyre mental. And correctional guards are not trained to
work with people with disabilities; they are trained in security work. We have got
mentally ill people who have been using substances to deal with their disabilities in
expensive government-run facilities called jails. It is not an effective way of dealing
with homeless, addicted, mentally ill people. (SP, Yellowknife)
Respectful and responsive
In the direct care process, each individual needs to be met where they are and as they are ready to
find a place and make a space. The relationship must be reciprocal, a collaborative partnership,
with the needs and readiness of the care recipient guiding the unfolding agenda. A menu of
choices needs to be offered and options provided with unconditional acceptance as a vital
prerequisite.
I think another reason our constituents come to us is because we give darn good,
comprehensive service in whatever will meet the constituents needs, so its
informed by constituents choice, constituents strength. (SP, Winnipeg)
10
Strengths-focused
Helpers need to believe in the ability of people to change while honouring their diversity and
finding strengths-based approaches that work for them. A strengths-based approach is more
positive and effective than a deficiency focus because it focuses on what the recipient of care
brings, including their culture. It looks truthfully at problems while patiently building on the
capacity and potential of the individual for positive change.
What we do works because we are building on strengths. Were building on a
positive foundation, and that makes all the difference in the world. (SP,
Saskatoon)
Flexible
Non-Government Organizations (NGOs) often are able to provide more individual, group and
community-based creative responses that are also cost effective. Government agencies have more
constraints around which they must manage in order to innovate and respond to community needs
and challenges.
What we do have as NGOs is a kind of freedom of thought; we dont have the
government culture coming down on us, having to tow the party line. (SP,
Whitehorse)
Flexibility in shaping a care plan according to individual needs and circumstances is a major
determinant of successful outcomes. Underlying this is the principle that the answers are within
us; the expert is the person who is living the life.
I dont know what these individuals have been through, so the client centered
approach allows me to let them heal at their own rate with the means they know
best rather than me imposing as an expert and telling them to do this. (SP,
Whitehorse)
Trauma-informed
Any effective service needs to incorporate a knowledgeable and skillful approach to individual
and collective trauma and racism while at the same time, recognizing and believing in peoples
capacity to embrace life in their own unique ways. While trauma is a reality in the lives of
many Canadians, for aboriginal people, individual and intergenerational trauma is too often a
consequence of colonial processes and practices. Historically and currently, aboriginal people
experience trauma related to the undermining of safe family and community connections, loss of
land, culture and language. Systemic racism, covert and overt, erodes a positive sense of personal
and cultural identity and wellbeing.
With our FN people, there are all those experiences of abuse added to the effects
of colonization on our people as a whole. (SP, Saskatoon)
Grief as universal
Unacknowledged losses are experienced by many Canadians. Indigenous people have a backlog
of grief connected to colonization and high rates of loss of all kinds that create a somewhat
unique context. To be effective, care providers need to understand how the burden of unresolved
personal and historical losses carried by many recipients of care may shape present behaviour.
11
They suffered, and because their children suffered, their grandchildren suffered.
Now I am saying each of these three generations needs counseling. (Community
Member [CM] Yellowknife)
Use human connection
Many aboriginal people have been deprived of human connection as a consequence of colonial
policies and practices such as the residential schools a foundational loss. To enhance and
augment the value of individual therapy, many care providers use small groups and other
collectives for re-creation through play, social and practical activities that support relearning the
healing nature of fun while building positive relationships and developing life skills. Some
services are activity based, rather than just talk therapy; for example, hunting on the land, going
fishing, making a meal, crafting an implement or camping. Participating in cultural activities
helps people re-build connections, not only to culture, but also to each other.
We do cultural skills trainingcabinet making, small tools, and repairing
snowmobile engines. (SP, Iqaluit)
5.3
Interpersonal Relations
Interpersonal relations refers to the range of relational networks and formal and informal
supports in which both the care provider and recipient of care are embedded, including
relationships with families, community members, colleagues, peers, mentors, supervisors,
other service providers and agencies. Focus group participants emphasized the importance
of reciprocity and dialogue, support for self-care, self-awareness, conscious growth,
spirituality and the necessity for circles of support for both care provider and recipient of
care.
Reciprocity and dialogue
The care providers work is characterized by a quality of reciprocity and dialogue based on a
perception of the recipient of care as equal in value to themselves, as being a teacher as well as a
learner in the relationship, and as capable of becoming proactive in building and maintaining their
wellbeing.
I learn something new every day from clients, who have a lot to teach us. (SP
Saskatoon)
Care for care providers
Self-care and personal growth are priorities for both care provider and the recipient of care. In
order to help others, practitioners must continually deepen the way they honour and nurture
themselves and role model a commitment to self-awareness, spiritual development and conscious
growth that supports their capacity to show up relationally. An outcome of the commitment to
nourish ones developing self awareness and personal capacity is a growing personal presence,
walking your talk and/or finding of voice for both provider and recipient of care.
if you are going to get into this field, in order to be of help to anyone you need
to be coming from a place of strength; that means I need to take care of myself
first. You need to deal with your own stuff first, so you dont put your stuff on to
anyone else. (SP, Whitehorse)
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We have a heal the healer first situation because we have students dealing with
abusive relationships, PTSD, substance abuse. We had to intensely work on getting
the potential healer to be healthy first sothere was a lot of work, academic and
counseling at the College. We hired a counselor specifically to work with the
mental health students because of the fact that we have such difficult issues to face.
So it is a continual work; it is not something that is going to happen in two years.
(SP, Iqaluit)
When renewal and healing is as much part of the human journey for care providers as recipients
of care, it contributes to a loving and intentional presence that is one of the most powerful gifts
one can bring to the other. Healing must be multi-faceted, realistic and a life-long process. We
each have our own ways to heal, grow and develop our gifts and full potential. Practitioners who
walk the talk are most effective in guiding people living with the challenges of mental health
issues through their own unique process.
Until you have something traumatic happen to you, its really hard to open
yourself to understand what other people are going through. I had some traumatic
things happen, so it just created something inside of me that I wanted to help. I felt
that my experiences made me a more caring, open, patient, understanding person,
and I find this job requires so much of that. And I think that I am good because I
am not very judging. I tend to just see people as people. You are not this illness or
that illness; you are just a human being. I try to be a good listener and try not to
say, you need to do this or you need to do that, and just let them talk and solve
their own problems by kind of guiding them through. Because I dont have all the
answers, and I believe that they do. (SP, Yellowknife)
Circles of support
By definition, circles are inclusive. Care providers see one of their most important roles as
bringing people into the circle, building social connections and peer support through healing
and recreational approaches as well as group therapy.
We do our Healthy Living Program; they make soup, socialize, and work in
activities. We always work in new ideas with input from the people that come.
Outreach does a lot of excursions in the summerlike going to have picnics and
barbeques and to just get folks out of town to see the wilderness and nature. (SP,
Whitehorse)
Care providers also recognize that there is a special quality in learning from peers and group
dynamics that allows them to work through family and group related traumas and find new
versions of family and community with the recipient of care. Importantly, providers see that
this applies to themselves as much as to recipients of care. They affirm the necessity for
supportive environments that promote their own personal and professional growth and
development, without which there is stagnation and burnout. Such supports sustain relational
practice, which thrives in a nurturing collegial community.
It is a difficult job to do on your own because clients are very complex. I do a lot
of networking. Networking is essential to me. (SP, Saskatoon)
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5.4
Professional Development
Professional development refers to the informal, non-formal and formal knowledge and
skill development received by professionals in the course of their training to become a
mental health practitioner, as well as the multiple life experiences and cultural practices
that care providers draw upon in their practice. Participants contributed the following
about professional development; insights about informal, non-formal and formal education/
training, mentoring, lived experience, balance and harmony, and wisdom teachings.
Education/Training
In every culture, education begins in our families and communities, where many of our most
important values, attitudes and beliefs are first nurtured. The institutions of the formal education
system are more successful when they build on the foundations laid in the early years. For many
aboriginal learners, there is a significant disconnect between the cultural orientation of home
and that of school, making it very challenging for them to reconcile and apply school learning to
the realities of their personal and professional lives.
When I took my social work training it was all westernized, there was nothing
aboriginal about it. Later training was all changed and I was able to really
incorporate a lot of what I had learnt there, because it was good, focused on
Northern remote aboriginal communities, and because I had already learned a lot
about my own culture and my own identity. (SP, Yellowknife)
For non-aboriginal service providers in mental health and addictions to be well prepared to serve
aboriginal people in culturally meaningful ways, their professional training must be congruent
with indigenous understandings of health, illness, healing and history.
We have people coming into social work who have very good intentions, they
want to be helpers. They are learning that the impact of colonization is still going
on, and instead of an approach to healing that medicalizes, they learn about
social suffering and the power of acknowledging where people are and that their
responses to atrocious things that have happened are pretty normal. (SP,
Yellowknife)
When formal education and training incorporates informal and non-formal strategies that allow
people to experience relational practice marked by ethical engagement, this can support and foster
human development, knowledge and skills acquisition. Methods for incorporating meaningful
teaching of relational practice and ethical engagement remain under construction. The following
strategies emerging in current mental health and addictions practice provide promising strategic
directions.
Mentoring
When done in a good way, the development of mentoring relationships across generations, across
disciplines, across agencies and across cultural divides can promote very significant learning and
support new capacity development related to relational practice and ethical engagement.
Mentoring and role modeling are powerful ways of teaching and learning.
People with more advanced training need to go to the smaller communities more
often to help support and train people working in the community. (SP,
Whitehorse) The nurses that are in a consulting role are using the resources in
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the communities to consult, to teach, to assist, all of that, so you are building up
your communities. (SP, Whitehorse)
Our team members have gone out to several of the communities and done microskills and counseling education so it builds capacity for them. We respond; we
dont impose. (SP, Whitehorse)
Valuing woundedness and healing through lived experience
We are all wounded and must honour our own woundedness. With our woundedness and our
commitment to healing comes an obligation to be fully engaged in our own lived experience. That
lived experience as it unfolds moment by moment is the crucible of relationship that we bring to
each engagement. This dynamic either affects our relational space within our awareness or out of
our awareness the effect is there either way. Deeply reflective practice involves seeing life as a
spiritual journey and opens the helper to be helped. To act out of unawareness increases the
potential to harm another. As we gain further awareness and proficiency in our own process, we
can help others. Many care providers and consumer advocates testified that their on-going
learning from self-reflection based on lived experience serves as their most valuable resource in
working with others.
If someone hasnt worked on their own stuff, they are of no help at all. (SP,
Saskatoon)
The significant difference between our organization and other organizations is
people on our board and people that work there have had problems. We have no
difficulty saying that we needed help and we had problems, and we helped each
other. (SP, Yellowknife)
Balance and harmony
Bringing people into the circle means providing a range of teaching and learning methods and
content options to people at the individual, family, group and community levels. Rural and
remote communities need relevant and accessible options and resources for building internal
capacity. Needs, strengths and resources must be balanced to support equitable access to
professional development opportunities that further support equity in health status for all
Canadians whatever their culture, geographical location, or socioeconomic status.
You need the diversity; you need the people on the ground who can be the
generalists, who can do the care, provide some problem solving and support, and
you need the people with the training who can guide the people on the ground or
assist when you have people who are suicidal. (SP, Whitehorse)
Wisdom teachings
Wisdom can be gained through experience and through spending time with people whose
knowledge is physically, mentally, emotionally and spiritually integrated. To find ways of
accessing wisdom from a spiritual tradition or traditions that are in alignment with ones path and
making time and space to learn is one of the best investments possible in human growth and
development. When practitioners have opportunities for interpersonal learning of wise teachings
from multiple perspectives without the privileging of one over others, they can build on the
strengths of all.
We dont need to teach the elders, they are already taught, and they are already
professors and experts in their domain. Its the people that we are training right
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now in schools that we have to help them to think about the strengths, and
alternative forms of healing for our people. (SP, Yellowknife)
5.5
Ways of Knowing
Ways of knowing refers to the approaches taken to understand, document and make sense
of the personal and social world. All my relations, cultural continuity, the power of story,
and tensions between Western and Indigenous ways are themes that emerged in the focus
groups.
All my relations
This phrase embodies the value and importance of relationships to generations that have gone
before (ancestors), the generations that will come after (yet unborn), land (a place that
remembers you), community, cultural and traditional paths, language and all elements of the
natural world. All of these are of central importance to most aboriginal care providers and
recipients of care, and become significant to non-aboriginal care providers working with
aboriginal people.
Cultural continuity
Some of the focus group participants spoke about the importance of Elders. Elders have enduring
lessons to teach with respect to rebuilding and maintaining health and wellness, generation to
generation. For many, Elders are the keepers of cultural continuity. They hold oral tradition; they
keep the stories and the songs. They do the ceremonies and teach others how to do the
ceremonies. Without relationships with Elders and their generosity of spirit in sharing what they
know, the rich wisdom that they carry will be lost. All of us need to be committed to learning and
sharing as cultural continuity is a collective effort with responsibilities for all.
I have been a survivor of suicide, I have been a survivor of mental health issues,
and the reason I was able to get back on my path was the culture. Without the
cultural teachings and without elders help I do not know where I would be today.
(SP, Winnipeg)
The power of story, re-storying and restoration
The power of stories was a strong thread in the focus groups. Indigenous people and client groups
are often the objects of stereotyping and social exclusion or victims of a single story that
simplifies and essentializes the diversity of human realities and in that process, dismisses much
that is true about the group about which the story is being told
(http://www.ted.com/talks/chimamanda_adiche_the_danger_of_a _single_story.html). Part of
therapy and healing is to understand how our stories are the outcome of our lives and contribute
to perpetuating patterns in our lives. We do not always tell ourselves a truthful or complete story.
The potential for restoration through re-storying our lives is powerful. The re-storying must take
place on both personal and societal levels, so both the care recipient, care provider, and the sociopolitical contexts in which they live are freed from the shackles of the dehumanizing single story.
Every person has his or her own story. You cant label because each person is
unique. (SP, Saskatoon)
One night I was sitting with three co-workers and started talking about treaties
and colonization. I was thanked by one co-worker who said she learned more from
me in 15 minutes than from all the hours of equity training, aboriginal awareness.
So, if that is going to be my role on the floor, I will educate them, I will try to
16
ignore their ignorance and their discrimination to hopefully help them see a little
more from my perspective, not the narrow view they have. (SP, Saskatoon)
Tensions between Western and Indigenous ways
Indigenous people with limited experience in highly complex government organizations often
need assistance in developing the organizational literacy to be able to see and deal with tensions
between what they may view as right and good and the organizational culture in which they find
themselves. Non-indigenous members of the organization also need help to make explicit and
change organizational values and practices that block effective service delivery.
When you end up working for government, it ends up being another level of
challenges because of the hours youre constricted to, or the office. Its just not
conducive to the cultural way of helping that was the reason they wanted to be
helpers, to help their community, and they end up having to use a government
process that is very foreign to them. (CM, Iqaluit)
Underlying these tensions is a fundamental difference in the ways in which mental health and
mental illness are conceptualized from western and aboriginal perspectives that has implications
for all aspects of a mental health system.
The frames of reference in FNs compared with the western world in terms of what
wellness means are radically different. (SP, Whitehorse)
Mental health is a very Eurocentric wordour government is thinking about this
as an individualized personal problem inside our minds and needs to think about
these concepts differently. (SP, Whitehorse)
For mental health, you have to know who you are, your history and where you
are going because it is the root of who you are. Mental health has to recognize the
treaty relations because that is the basis of who we are within Canada and thats
what cultural safety is. Its us running our own organizations, our partnering, but
we are real partners; we are not just at the table. (SP, Yellowknife)
5.6
Organizational Context
Organizational context refers to workplace norms, policies, resources, agency mandates and
professional routines. Focus group participants spoke about organizational norms,
centralization vs. decentralization, integration of services, family and community context,
and healthy effective organizations.
Organizational norms
Positive norms support good practice. In organizations, there may be tensions experienced
between indigenous and non-indigenous ways of knowing being and becoming when culturally
different groups work together. The indigenous imperative to be respectful and responsive to
people, sometimes at the expense of policy is not always supported in organizations. Concerns
about budgets and efficiency may well trump client-centered concerns. Indigenous ways of
knowing are relationally led and informed. From an indigenous perspective, the needs of the
recipient of care ought to guide the helping process, and policies and procedures that block or
circumvent effective practice need to be identified and addressed.
17
We are status blind; we serve anyone who is aboriginal, Inuit or Mtis. (SP,
Winnipeg) The two systems (First Nations and non) are so different. One is about
appointments and procedures; these did not work in the small communities. (SP,
Whitehorse)
With the amalgamation of services, the manager role is more worried about
admin and financial management (not paying overtime or sick time) than
developing teamwork. There is no teamwork on our floor. Five years ago, the focus
was on the best patient care. The team leader was accountable, looked after the
staff so they could be well rested and provide the best patient care. The new
manager came in with different values. His approach is all about the budget and
time management. If he meets the budget he gets a nice bonus at the end of the
year. (SP, Saskatoon)
Your system reflects your approach. When I was hired, my boss said here we
arent hierarchical; we are all equal whether your work is to answer the phone and
greet people or you are a clinician. We are on one page, every opinion matters,
everybody is deserving of equal respect. So that whole kind of we are one, we are
equal philosophy passes down to clients. (SP, Whitehorse)
Centralization versus decentralization
Many participants noted the importance of aboriginal self-determination. Autonomy and selfdirection at the community level ensures the best fit of service to need. A balance of centralized
and decentralized services needs to be achieved and maintained dynamically in order to maximize
the effect of resources invested and to get the services as close to the people as possible. For
example, organizations that provide services to rural and remote populations need to have the
authority and capacity to design and deliver appropriate programs and services to diverse and
dispersed people.
The biggest need is for a proper community-driven mental health facility because
people here are still skeptical about the people who caused the problem now
being the solution to it. (SP, Iqaluit)
Integration or linking of services
Innovation is needed in some cases to find new ways of integrating, bringing together or linking
services. Focus group participants talked about people getting lost in the cracks due to lack of
good linkages that work for people. Many participants spoke about the need for health services to
link with housing and educational and employment opportunities.
Like for me its hard to find a decent job because Ive got no education. I cant
really get anywhere unless I try,
It would be good to have small-income loans and low-rental places for people
that need a place to stay. (Service Recipients [SRs], Yellowknife)
Housing is a huge challenge for a lot of people, especially for women. (SP,
Saskatoon)
Partnering between agencies or individual helpers is one way to increase capacity and ability to
serve.
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5.7
Policy Challenges
align with each other in order to maximize the ability of government and non-government
community agencies to serve people. Ensuring sustainability for programs and services of proven
effectiveness is also a challenge.
Temporary funding is not the way to meet the health needs of the North. (SP,
Whitehorse)
Theres a lot of catches to this funding money. We operate, from quarter to
quarter and uncertainty is the biggest problem we face because people are fed up,
rightly fed up, after many years of programs being started and they start to
improve their lives and all of a sudden your funding disappears and the programs
gone. Thats the biggest problem is the sustainability. We are looking to having to
close the doors on March 31st after six full years thanks to the Aboriginal Healing
Foundation (AHF). And this year, we are $8500 short because the feds havent
come through with the money though we signed the papers. I say live up to your
commitments because if you dont, you kill the program. (SP, Iqaluit)
Individual rights and collective responsibilities
The mainstream system is focused on individual rights as a primary concern that supports a
policy response to individual needs. From an indigenous perspective, collective responsibilities
are seen as primary and therefore the most important response focuses on the nexus between
individual and collective responsibilities. Rights, in the indigenous view are earned through
carrying out responsibilities in ways that benefit present and future generations.
What would it look like to create a truly family friendly service that engages the
family and community? We dont think the language of diagnosis is friendly and
office hours are unfriendly; there are a lot of things that are unfriendly. (SP,
Whitehorse)
Biomedical model, indigenous and complementary approaches
The biomedical model often stands in opposition both to indigenous and complementary
approaches that are more holistic, whereas the biomedical tends to be an individualistic, curative
perspective. Indigenous and complementary philosophies and methods are usually congruent. The
predominance of the biomedical model is problematic as it leaves little room for these other
models. Sometimes, for individuals struggling with indigenous identity, complementary
approaches offer a pathway more acceptable to them. Participants called for building approaches
that respond to multiple ways of knowing and multiple pathways to healing and recovery.
Our program activities are holistic; a blend of contemporary and traditional
services to meet the complex needs of our urban aboriginal population in order to
move them to a healthier lifestyle. We like to say we take the best out of both
worlds. (SP, Winnipeg)
Capacity for response to ethical dilemmas
Both individuals and organizations often find themselves faced with ethical dilemmas, some of
which have cultural and professional dimensions. As one person said,
Who is it we go to when something happens that we cannot tell anyone about?
(Symposium Participant [S], Ottawa)
20
Organizations need to have capacity to assist in these situations to prevent ethical blindness,
burnout or moral residue as a consequence of unresolved ethical tensions that may compromise
relational capacity at the service interface. Truth telling and speaking truth to power must be
supported in order to build and keep trust. A recurrent example of a major ethical dilemma is the
lack of program sustainability.
Programs actually come and go so frequently that they put people into a worse
situation than they were to start with. (SP, Iqaluit)
6.0
Discussion
The discussion is founded on the results of the literature review, a synthesis of views from
participants, the analysis of the experience of the focus group facilitators, and the dialectic created
in the relational space between the two. In this section, the voice of the report intentionally moves
to we in order to speak collectively about what we have drawn as conclusions from the findings
and the learning that emerged from our collective intent as a working group to walk the talk.
The discussion blends the shared learning from the focus groups with personal and working group
insights developed through dialogue with the data and each other. We chose to model inclusion,
participatory methods and indigenous ways of sensing and sharing knowledge and wisdom in
choosing our methods with the focus groups and within the working group. In both groups, we
honoured the principle of allowing the participants to direct the process as it emerged organically
from one stage to the next.
6.1
The wise and responsive leadership expressed by Bill Mussell was fundamental to our collective
learning. As a result of his lifelong learning, Bill was able to design an open process for the focus
groups that was both inviting and generative. He and Terry Adler created a space together of
loving interest and inclusion that promoted significant contributions and deep sharing among
participants. Focus group meetings were planned to optimize the comfort level of participants by
being held close to home in familiar surroundings with participants who either knew one
another or had much in common.
The talking circle as a method worked well, due to the way in which it was introduced at the
sessions. The facilitators intentionally remained open and responsive to whatever emerged from
the group. The perspectives of all participants were valued and the circle was kept and held until
it was finished time was provided to allow for consensus or a natural conclusion. Bill Mussell,
as the primary circle keeper, demonstrated the loving presence, non-judgmental acceptance and
openness that invited people to feel safe and contribute to the level that they felt comfortable. As
facilitators, he and Terry were able to help participants find ways of safely being on the bridge
the bridge between aboriginal and non-aboriginal worlds; between care providers and those
receiving care; and between community and institutional ways of caring. Learning and discovery
was encouraged and mediated under their leadership. Each group was seen as a microcosm of the
whole and an opportunity to experiment with walking the talk together. The process was cocreated by all the participants, and the responsibility for the outcome jointly taken.
The working group came together under the leadership of Mussell and Adler to work with the
information and knowledge that they had collected and generated throughout the data collection
phase. There was a commitment within the group to affirm and reaffirm a collective belief in a
21
hopeful future. We were invited to hold hope in our hearts and to focus on strengths and
possibilities while facing the current reality with unflinching courage. As we discovered, in order
to hold the findings we had to be willing to let the information and growing awareness transform
us. Through the emergent process, we were challenged to embody the current reality in order to
hold the possibility for change in our conscious awareness individually and collectively. The
work both in person and through technology took on a loving, emergent quality and together we
created the perspective needed to ensure we honoured the voices of those that took part and the
many individuals with lived experience that were not able to participate. A profound valuing of
the opportunity to connect with one another and make a hopeful difference became the wellspring
that fed the work. The work was alive with generative cross-pollination of ideas and divergent
perspectives.
Intentionality became an operative word as we visited and revisited our intentions. Meetings
always began with a check-in circle to honour the fact that we bring all that we are and the
connections that define us, including family and friends to the circle. In the circle, we were
invited to show our whole face. Even our pain and distraction were welcome as signs of where
we were, in our personal process of becoming on that day. The embracing energy of acceptance
and allowing permeated the circle. We intended to make a contribution to positive change while
honouring the voices of all who participated. We intentionally used space and time as a precious
resource and valued reciprocity and mutuality in our relationships. The process was more of a
spiral than a linear progression as we used indigenous ways of being together in dialogue and
taking collective ownership of our work.
The view was a long term and patient one; the collective stance humble. Collectively, we hold an
unfailing belief in individuals willingness and ability to change themselves, sometimes with the
assistance of a hand up which is offered with high regard for their experience in that moment.
We intend to do what we can. There was a distinct absence of ego driven competitiveness or a
need for recognition and ownership. The work was truly spirit-led and spirit-assisted. A sense of
hospitality and generosity prevailed as we cared for one another through the process. We invited
each other over to our home perspectives with the enthusiasm of the best host or hostess. We
trusted each other and the process enough to sit and visit with it until the next important
realization bubbled to the surface and the next step became clear. Each individual and his or her
sense of a need to protect home territory was honoured.
6.2
From this project emerges a new way of understanding and responding to mental health
and addictions as a human experience, best expressed as principles and practices that apply
to related programs, services and the systems supporting policy and program development
and service delivery.
Honouring humanity and human experience in the process of becoming
Honouring humanity and the common ground of human experience entails recognizing pain in all
of its human dimensions, supporting the voice of those who often do not have opportunities for
expression, and affirming the health and resiliency of individuals, families and communities.
In the practice of asking people, being helped how they are becoming and honouring their
evolving process, the care provider offers stewardship in the care recipients process of healing,
growing and re-creating self.
22
23
Following from patience is the ability to listen deeply to the other and hold space for their dignity
to be protected and expressed.
It makes a lot of difference when somebody actually listens to people. (SR,
Yellowknife)
Radical acceptance
Valuing each person and accepting the way they are provides a place for meeting them there and
moving from that point together. Valuing and acceptance is at the heart of non-judgment. This is
not to say that all behaviour can or should be accepted and allowed in all circumstances.
Unconditional love and acceptance and deep valuing can co-exist with setting limits to behaviour
if needed.
In my work with people because Ive been judged a lot in my own lifetime, is just
to practice acceptance and see that person as a human being, not with all the
garbage that is in the way, but underneath that. Because that is who they are is
whats underneath there, not all this other stuff theyve been clouded up with,
through a lot of times, no fault of their own. (SP, Yellowknife)
Reconnection with self, others and the natural world
Illness is the result of disconnection and imbalance and therefore healing and recovery is founded
on supporting reconnection with self, other, family, community and the natural world.
Disconnection is from culture, from selfhood, from your own sense of agency;
disconnect on a community level. It is pervasive. These are communities
characterized by disconnection [within the community] and disconnection between
the services and the population they are supposed to serve. (SP, Whitehorse)
The balance of connections and the personal balance of mind, body, spirit and heart further the
capacity for connection.
So when they sent me back to my own people, they taught me how to take care of
myself properly, they brought me back to praying, back to spiritual ceremonies and
stuff like that. And they talked to me; they taught me how to be clean, how to
survive, how to believe in myself, and how to feel more compete as a person. (SP,
Yellowknife)
The practices of being with in silence acknowledge the therapeutic value of being not
doing. Land based healing allows for periods of quietude on the land in connection with nature,
and time to be with one another in small groups or around a fire where people may companion
each other in silence, with little talking or activity. Taking time alone to connect with self, reflect
on ones inner dialogue and experience as part of healing is a well supported indigenous practice.
Respect
Respecting the lived experience of care recipients, their family, friends and care providers is
essential to honouring them and their process of becoming and healing in the world. A person can
never know the full extent of anothers inner world but relational practice and ethical engagement
can provide a safe bridge into a deeper and more authentic understanding of the other.
Most of the family support work we do is trying to get from them how they see
their world, how do they perceive it. It is all about hearing from them. (SP,
Yellowknife)
24
People come because they feel safeothers have told them it is okay to come
they are not going to be judged or pathologized or labeled with the problemthey
just need somebody to talk to and to know that they are actually present. To me if
you cant be present, go drive a truck. It is about balancing out the pain with the
hopes, and to be able to hold both. (SP, Whitehorse)
Collective healing
Building from existing family and community capacities strengthens natural social networks,
rather than setting them aside. We need to honour peoples existing social networks and those
they identify as family. Many one-to-one services disrupt family and community cohesion and
fracture community connectedness. While we understand that not all relationships are always
helpful or positive, we know that people are embedded in their social systems and healing needs
to be supported at the collective as well as the individual level.
We are dealing with a traumatized community. Its not just where the individual
is at; it is where the community is at. Government has made huge errors going in
with guns blazing saying here is what we will give you, when the community didnt
invite them and hasnt been consulted. (SP, Whitehorse)
Inclusive communities of practice
The idea of community of practice or community of care is important in supporting the ongoing
growth and development of care providers both paid and unpaid. Collaborative relationships
within and between agencies provide for a spirit of working together creating attunement and
synergy that better serves the people. Communities of practice need to embrace a diversity of
helpers. When one person is the expert, there may be little room for learning.
They (women in a federal prison) reminded me that I was just the same as them.
Just because I am a Doctor doesnt mean I know it all and I would refer them to
others who knew more than me. You are there more as a guide. Being humble, not
acting as an expert is part of cultural safety. (S, Ottawa)
Strengths-based approaches
Working from a focus on the strengths and capacities of a person or group is to affirm the positive
and build from what is known to be strong. In Appreciative Inquiry this is known as seeking out
the life giving forces, seeing them clearly and investing in them as a source of positive growth.
What we do is development with them, capacity building. We get them to realize
that they do have the solutions and that they are the ones who are the experts.
(SP, Iqaluit)
Relational attunement and shared living
Love and loving presence contribute to resonance between people. This is a deep and restorative
form of connection. It is being in tune with the other and is a powerful antidote to fear, shame,
and toxicity. Resonance signals the engagement of the heart and spirit, as well as the head.
Showing people how to live and how to live together by doing it reinforces that you embrace life
by living it (S, Ottawa). Some people have forgotten how, so we need to live with them through
life experience and help them relearn how to embrace life again.
25
It is important to identify and manage fear due to individual vulnerability or the emergence of
relationship challenges, either as expressed by the recipient of care or the care provider. It is
working with our soft spots that promotes change.
Honouring boundaries
Honouring personal and collective territory is important as individuals learn and relearn
boundaries and boundary setting. Part of defending boundaries is strengthening the ability to
resist influences that are harmful. At a community level boundary setting is about protecting and
preserving land as a steward.
Recovery model
The recovery model has many helpful principles and practices including the use of peers and
community agencies. It recognizes that recovery in addictions and mental health includes relapse,
and often, movement onto further stages of recovery. Individual recovery needs to be supported
by family and community level recovery. Policies and practices that govern the provision of
programs and services should support recovery as a process at all levels. The recovery model
used must be reflective of indigenous ways of knowing, culture, values and healing methods.
I have been working in recovery for years with people on mental health on an
individual level, but there is recovery at a bigger level as well. There needs to be a
sharing of power and resources, and the respect for where people come from. For
the aboriginal communities, they need to be the drivers. (SP, Yellowknife)
Nature as healer
Relating to and learning from nature is helpful in rebuilding connections.
On the land is where everybody is connected together, in every aspect of our life;
our physical, our mental, our emotional, our spiritual and socially too, because its
all there together. (SP, Yellowknife)
Working with the seasons can put a person in touch with the ebb and flow of life and assist in
learning how to let go and move on with a new season, in harmony with the cyclical nature of
life. Activities in the natural world can reawaken peoples stored cultural knowledge, sense of
spiritual connectedness, and hope.
I had a womens mobile on the land program years ago that went from one region
to the next. By the third week, the change in the women was just amazing. The
results would not have happened within an institution in three weeks. No way. No
way. This sort of thing with the land is more spiritual and grounding and there is
more support for your emotional disarray that nature will provide for you. You
dont need words. (SP, Yellowknife)
If I had the funding, I would do an on the land type of treatment program. Once
they go out on the land, our people are totally different people. When you are out
on the land there are so many different aspects of the life that touches peoples
lives. One of the findings of the evaluation of the program was how those women
really felt more empowered when they were on the landit made a huge difference
in the dynamic. (SP, Yellowknife)
26
6.3
Metaphors
27
6.4
Liberating concepts
Liberating concepts are ideas that provide a foundation for redesigning our systems of care.
Concepts that emerged from the analysis of information provided by focus groups and the
Ottawa symposium include:
Many choices and freedom to choose
Choice requires access to options and exercising choice can be a powerful process of defining
personal preferences that fit with an individuals healing path.
The opening up of spaces for many choices for people is critical. (S, Ottawa)
Return to the large human tribe
Our connections, as human beings are founded in our shared humanity and characteristics which
support much common ground.
With a focus on technology over empathy we are sub-dividing ourselves into
smaller and smaller tribes, none of whom will be able to speak to each other.
Rather than a technical approach, adopting a more holistic one characterized by
compassion and empathy has the power to reconnect us. (S, Ottawa)
28
29
30
7.0
Way Forward
The findings from the Western focus groups point to practices that can contribute to
transformational change of the current mental health and addictions systems if they take place
across multiple sites, including: individual, community, organizational and social structural
contexts (Prilleltensky & Prilleltensky, 2006). Such practices, as described by focus group
participants, can be summarized as safe, ethical, respectful, critically conscious, culturally good
and socio-politically aware. The authors of this report explicitly recognize that an over reliance
on micro-level practices or individual change efforts will not produce a transformed mental health
system. We invite readers to think deeply about how to bring such practices into their own
domain, whether that be individual practitioner/client interface, groups within organizations or
agencies, the full organizational level, or the system-wide level, which includes practice, program
design and policy.
The ideas shared in this report can act as a filter or perceptual lens. The use of this particular
stance or approach when entering discourses can influence the quality of questioning and thinking
to guide you into the next level of learning. This information can inform the evolution of your
practice and affect the quality of your relationships, particularly inter-cultural relationships. It can
also provide a foundation for program development and policy work.
We hope that the thoughts collected in this paper will serve to guide the work of the MHCC in
developing and implementing strategies for transformational change. The results from this project
have already been used by the project team for curriculum development. Through the use of
cultural methods and experiential learning, the curriculum will be a valuable tool to translate the
knowledge from this project.
The authors invite feedback on the ideas presented so that we may collectively further our
understanding and engage collaborative planning and action. Please direct your feedback and
ideas to the Project Lead Bill Mussell by email nmha@telus.net or mail to Native Mental Health
Association of Canada, Box 242, Chilliwack, BC, V2P 6J1.
31
Appendix A
Demographics: Western Canada Focus Groups
Demographic
information
Number of participants
(N=147)
% of Sample
Gender
Male
Female
42
105
28%
78%
Ethnicity
Aboriginal
Non-Aboriginal
97
50
66%
34%
39
108
26%
74%
12
28
28
60
19
8%
19%
19%
40%
13%
Relationship with
Services
Consumers
Service Providers*
Location
Saskatoon (5 groups)
Winnipeg (5 groups)
Iqaluit (4 groups)
Yellowknife (7 groups)
Whitehorse (6 groups)
* Individuals were identified as per the primary role each took in the discussions. At least 25% of
Service Providers indicated they had lived experience of mental illness, though they may or may
not have accessed conventional services in their healing process. At least half the Service
Providers made reference to their supportive roles with family and/or community members who
were experiencing or had experienced mental health challenges.
32
Appendix B
Abstract: Cultural Safety Literature Review
This report provides a critical exploration of the notion of cultural safety as it pertains to health
care and Indigenous health. The notion of cultural safety is a relatively new concept that has its
origins within the Maori nursing education context of New Zealand. Over the last decade, this
concept has transcended national boundaries and increasingly gained international influence
across a variety of professional and political organizations and associations concerned with
redressing health inequities and achieving social justice. Firmly positioned within the paradigm of
critical theory, the concept of cultural safety is used here as an interpretive lens to focus attention
on social, structural and power inequities that underpin health inequalities/disparities it prompts
a moral and political discourse/dialogue. Cultural safety is, therefore, not about ethno-cultural
practices, rather it highlights the need for the development of critical consciousness toward the
power differentials inherent in the health care system as well as the broader socio-historical and
political factors that shape health care and Indigenous health. Guided by the lessons learned from
the New Zealand experience in implementing cultural safety into nursing education and criticaloriented knowledge derived from recent research on cultural safety outside its original context,
this report critically discusses how to bring this agenda into relief in all areas of practice
clinical, education, research and policy.
33
Appendix C
Demographics: Eastern Canada Focus Groups
Demographic information
Number of
participants (N=99)
% of Sample
Gender
Male
Female
32
67
32%
67%
Ethnicity
Aboriginal
Non-Aboriginal
45
54
45%
54%
47
5
47
47%
5%
47%
Location
Halifax (4 groups)
Moncton (2 groups)
St. Johns (2 groups)
Montreal (2 groups)
North Bay (2 groups)
Sudbury (2 groups)
24
16
13
16
14
16
24%
16%
13%
16%
14%
16%
Some individuals fit into more than one category; each person was identified as per the primary
role he or she took in the discussions.
34
Appendix D
Cultural Safety Project: Eastern Canada Focus Group Report
February 18, 2010
Executive Summary
Introduction
In 2009, the Native Mental Health Association of Canada and the Mood Disorders Society of
Canada partnered to commission a series of focus groups across Canada as part of their Building
Bridges initiative. The report reviews the findings from 14 focus groups held in Eastern Canada
between November 2009 and January 2010. Participants included Aboriginal and non-Aboriginal
consumers, family members/caregivers and service providers. The purpose of the discussions was
to further knowledge and understanding of what happens when people attempt to access mental
health and/or addictions services, what happens when they succeed in accessing services, what
makes them feel safe and comfortable or not with the services, and what actions they take to
protect and promote their own mental health.
35
The only way to get in [to mental health services] is if you threaten to kill
yourself. And even then, you will have to wait. (Consumers, North Bay, Ontario)
With the exception of a small minority of consumers, all of the focus participants experienced
some difficulties accessing mental health or addictions services. The main challenges people face
when seeking services are listed below.
1. Lack of awareness of what services are available and how to access them, reported by seven
groups.
2. Unavailability or limited availability of services, reported by 14 groups.
This includes accessing family physicians, community-based psychiatrists, non-medical
interventions such as psycho-therapy, treatment for concurrent disorders and culturally safe and
sensitive services for Aboriginal people and newcomers. Services are especially limited in rural
and remote areas.
3. Long wait times for services, reported by 12 groups.
I think consumers who have the courage to keep trying when there is a six
month wait list - we dont say that if someone has a broken leg - they are
incredibly strong and patient people. (Service Provider, Halifax, Nova Scotia)
4. Having to push hard and advocate for themselves to get the care they need, reported by four
groups.
Its a brutal task to try and get services, especially on your own.
Especially when youre not well. (Consumers, St Johns, Newfoundland)
36
Their concerns pertain primarily to unnecessarily long wait times, over-use of police and security
guards who are not properly trained, and disrespectful treatment by service providers.
2. Concerns about assessments and diagnoses, reported by 13 groups.
I know diagnosis is important but are we going to get the right one, or
get one just because of how we look? (Aboriginal Consumer, Halifax,
Nova)Scotia
Concerns revolve around the timeliness and accuracy of diagnoses, including the criteria used to
make diagnoses and the fact that diagnoses rarely involve a consideration of the consumers life
experience and cultural context. This is a concern for Aboriginal people in particular, many of
whom are living with the effects of inter-generational trauma from colonization.
3. Experiences of disrespect, condescension, stigma, racism or discrimination from service
providers, reported by 14 groups.
We need professionals who treat you like a human being.
Consumer, (North Bay, Ontario)
Participants from all of the focus groups related incidents where consumers were treated
disrespectfully and with a distinct lack of compassion by service providers. This has happened
with a broad range of service providers including mental health care providers, health care
providers and others (e.g. welfare workers). Many consumers talked about being treated like a
label or a number, rather than a person. Many also spoke of feeling unheard, judged and .looked
down on, as if they were inferior in some way to the service providers. Those who had tried to
complain found that their complaints were ignored or dismissed. People who have addictions, are
poor or are Aboriginal are especially likely to feel judged and stigmatized and to experience
discrimination from mental health service providers
4. Biomedical, rather than holistic and recovery-focused services, reported by 14 groups.
Everything cant be fixed with a pill. (Consumer, North Bay, Ontario)
Concerns here are based on a heavy emphasis on medication as the main treatment modality, the
lack of attention by providers to the context within which mental health or addictions problems
arise and the tendency to treat consumers as diagnostic labels rather than whole persons.
5. Fragmented and uncoordinated services, reported by 12 groups.
Because organizations tend to operate as silos, services are limited, not linked with each other,
and difficult to access. Consumers with multiple needs are often bounced around from one
service to another. As a result, they have to tell their stories again and again and there is no
continuity of care. This is especially frustrating for people when moving to one service system to
another, i.e. from childrens mental health to adult services. Consumers and family members
find it very challenging to have to navigate these service systems on their own and coordinate
37
their own care. The disconnection between mental health and addictions services is especially
troubling, as participants see a strong linkage between the two. One of the largest gaps seems to
be between the health system and the community organizations that offer self-help and peer
support programs. People often stumble upon these supports on their own, having failed to
receive any information about them from health care providers.
38
1. Feeling alone, uncared for, unheard, judged or disempowered, reported by eight groups
Feeling safe with mental health people is frustrating because you cant
feel safe; there is no one looking after you. (Consumer, Halifax, Nova Scotia)
When people feel that no one cares about them or listens to them, or that they are being judged
and found wanting, this makes them feel uncomfortable and unsafe. The power imbalance
between consumers and service providers can make consumers feel unsafe, especially if they
have emigrated from a country where abuse from the military or police was common. This is also
true for consumers who are mandated to take treatment.
2. Models of service that do not meet their needs, including their cultural or linguistic needs,
reported by eight groups.
Consumers and family members may feel unsafe when models of service do not meet their
specific needs. For example some feel safe only when they are at home, often because of a history
of abuse, and they would prefer to be able to access services at home through telephone lines or
outreach visits. Many consumers, family members and service providers also noted that services
are not sensitive to the unique cultural and linguistic needs of newcomers and Aboriginal people.
3. Experiencing racism, stigma and/or discrimination, reported by seven focus groups.
Its really frustrating. Im trying my best but I fear that people will always
see me as a junkie and a thief. (Consumers, North Bay, Ontario)
39
Someone needs to look at the big picture and how the money is being spent.
(Consumer, St Johns, Newfoundland)
With regard to where funding should be allocated, a number of participants would like more
money dedicated to prevention and early intervention services. Many participants would like to
see more resources dedicated to community-based services and organizations, particularly
organizations that provide family and peer support services. A number of people said that these
organizations are doing excellent work, with woefully inadequate funding.
40
41
support, mental health and addictions problems are more likely and recovery becomes extremely
challenging.
8. Engage and support family members and caregivers, reported by four groups.
While recognizing issues of privacy and consent, family members and caregivers would like to be
more engaged in the care of their loved ones. If they had more information and were more
engaged, they could be more helpful in the recovery process. Family members and caregivers also
need recognition for the important role they are playing, along with support for themselves. It can
be stressful and exhausting caring for a loved one with a mental health or addiction problem and
this can affect the well-being of the caregiver. Some have found family member/caregiver peer
support to be particularly beneficial.
42
43
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i
In this report, we use this terminology as consistent with the terminology used by the Royal Commission
on Aboriginal Peoples (1996a). The term Aboriginal peoples refers generally to the Indigenous inhabitants
of Canada, including First Nations, Mtis and Inuit peoples without regard to their separate origins and
identities. When distinctions between Aboriginal groups are needed, specific nomenclature is used. We use
the terms Aboriginal and Indigenous interchangeably in this report.
47