Building Bridges 2 – A Pathway to Cultural Safety, Relational Practice and Social Inclusion

Schedule A

Supporting the Mental Wellness of First Nations, Inuit and Métis Peoples in Canada: Cultural Safety
A Research Discussion Paper

Section 1.0: Introduction

1.1 Background

In an effort aimed at modifying the status quo and ensuring that the Canadian mental health and addictions systems respond appropriately to the needs of First Nations, Inuit and Métis and other mental health and addictions consumers and their caregivers, the Native Mental Health Association of Canada (NMHAC) and the Mood Disorders Society of Canada (MDSC) have launched Building Bridges II: A Pathway to Cultural Safety project. In keeping with their initial Building Bridges Project (2008/2009), both the NMHAC and the MDSC engaged in dialogue with their respective First Nations, Inuit and Métis communities and provincial Mood Disorders Associations and other provincial and local consumer networks regarding the notion of cultural safety and attendant practices that support mental health and well-being.

The two national NGOs are collectively developing a comprehensive planning framework on cultural safety which 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.

As part of this landmark partnership for improving mental health in Canada, the NMHAC and MDSC commissioned this paper to research and analyze cultural safety and cultural competence as tools to deal with identified inequities in health, education and social services. The two organizations wish to develop a national framework for ensuring culturally and linguistically competent and safe mental health and addictions services for indigenous and non-indigenous mental health and addictions consumers.

The Native Mental Health Association of Canada and the Mood Disorders Society of Canada have a rich history of working collaboratively and sharing their respective expertise in regard to “what works” and “what does not work” in mental health and addictions programs and services. Groundbreaking national initiatives comparing and contrasting similarities and differences between their indigenous and non-indigenous constituents, along with finding common ground and identifying goals for future collaboration, serve as the pillars of this unique and effective partnership in Canada.

The purpose of this report is to provide an overview of current conditions and possibilities re: culturally safe and competent mental health and addictions services for First Nations, Inuit and Métis in Canada. First, we provide a brief introduction to key definitions used in this paper and to the concepts of cultural safety and cultural competence. Secondly, we provide a brief overview of the mental health and well-being of First Nations, Inuit and Métis in Canada in the context of colonial and neo-colonial processes and polices in which mental health and addiction services have been and continue to be provided to First Nations, Inuit and Métis, i.e., why the need for cultural safety. Then we move on to highlight the possibilities, i.e., how cultural safety could be used to create a space for critical reflection and dialogue within the mental health and addictions systems, a dialogue that would lead to action, improved mental well-being for all Aboriginal peoples and health equity for all people in Canada. Lastly, we engage with the concept of cultural safety as a means to support social justice and the mental well-being of First Nations, Inuit and Métis in Canada.

The goal of this paper is not to provide an exhaustive review of the available data, rather it is to highlight knowledge from various sources that provides insights into the topic of this report.

1.2 Key Definitions

Several key definitions are provided to ensure that the reader is clear about the way we are using various terms in this report. In much the same way as we have used the terms referring to Aboriginal peoples in prior literature (e.g., Browne, 2003; Browne, MacDonald & Elliott, 2009; Smye, 2004), we use these designations 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, Inuit and Métis peoples without regard to their separate origins and identities. The Royal Commission stresses that the term Aboriginal people “refers to organic political and cultural entities that stem historically form the original peoples of North America, rather than collections of individuals united by so called ‘racial’ characteristics. The term includes the Indian, Inuit and Métis peoples of Canada (see section 35(2) of the Constitution Act, 1982)” (p. xii). Specifically, the term “First Nation” replaces the term “Indian” and “Inuit” replaces the term “Eskimo”. The terms Indian and Eskimo, however, continue to be used in federal legislation and policy, for example, the Indian Act, and in government reports and statistical data, particularly those generated by the federal department of Indian and Northern Affairs Canada (INAC). INAC retains the terms “status” or “registered Indian” to refer to people who have been registered by INAC as members of a First Nations under the terms of the Indian Act. In this report, the term “Aboriginal peoples” is used to refer generally to the diverse groups of indigenous peoples within Canada. When distinctions between Aboriginal groups are needed, specific nomenclature is used

We use the notion of mental wellness in keeping with the perspectives of the First Nations & Inuit Mental Wellness Advisory Committee (MWAC). After reviewing the Mental Wellness Framework (2002), and the National Native Alcohol and Drug Abuse Program (NNADAP) Renewal Framework (2000)¹ and to honour principles of wholism, connectedness, togetherness, cultural ways of knowing and core cultural institutions such as the family and community, the following definition of ‘mental wellness’ was chosen by MWAC (2007):

Building Bridges 2 – Schedule A3 Mental wellness is a lifelong journey to achieve wellness and balance of body, mind and spirit. Mental wellness includes self-esteem, personal dignity, cultural identity and connectedness in the presence of a harmonious physical, emotional, mental and spiritual wellness. Mental wellness must be defined in terms of the values and beliefs of Inuit and First Nations people (Mental Wellness Framework, 2002, as cited in MWAC, 2007, p. 25).

In the same vein, an Inuit-specific Mental Wellness Action Plan was developed and the following definition used:

Mental wellness is defined as self-esteem and personal dignity flowing from the presence of harmonious physical, emotional, mental, spiritual wellness and cultural identity (Inuit Specific Mental Wellness Framework, 2001, as cited in MWAC, 2007, p. 40).

According to the MWAC, ‘mental wellness’ is inclusive of “mental health, mental illness, suicide prevention, violence reduction, and reduction of substance abuse and addictions” – all components that contribute to a balanced life. It involves a holistic approach that brings together: i) Prevention and promotion; ii) Treatment, intervention and aftercare; and iii) Traditional knowledge and practices (p. 41).

¹ These frameworks resulted from collaborative processes with key stakeholders, received a high degree of support from First Nations and Inuit communities, and set mental health and addictions within the context of the broad determinants of health (MWAC, 2007).

1.3 Cultural Safety and Cultural Competence: A Critical Cultural Perspective

In this report, we examine the possibilities and challenges attached to the use of the concepts of cultural safety and cultural competence to support the mental health and wellbeing of Aboriginal peoples in Canada; this in response to i) colonizing processes that continue to privilege dominant culture perspectives in the construction of the mental health and addictions services, e.g., Aboriginal people tend to not use mainstream health care services, present at advanced stages of disease progression, show “non-compliance” and often drop out before the end of treatment; and ii) a recognition of the limitations of ‘culturalist’² approaches in response to these issues (Browne & Fiske, 2001; McCormick, 1996; 1998; McGrath & Phillips, 2008; Nguyen, 2008; O’Neil, 1993a, 1993b; Smye & Mussell, 2001; Wilson, 2008). In our view, cultural safety has particular relevance because it draws attention to the issues embedded within the social, historical and political context of mental health and addictions care delivery –it is intended to shift attention from the ‘culture’ of the ‘Other’ to the culture of [mental] health care and structural inequities and draw attention to and address the power relations that shape [mental] health [and addictions] services and health (Anderson et al., 2003; Browne, 2005, 2007; Browne & Smye, 2002; Browne & Varcoe, 2006; Hartrick Doane & Varcoe, 2005; Smye, 2004; Smye & Browne, 2002; Smye, Willis & Rameka, 2006).

Increasingly, ‘culture’ is used in health care (and more widely) to explain difference in ways that overlook structural inequities and imply inferiority (Reimer Kirkham & Anderson, 2002). “Common applications of the construct of culture may draw on historical and colonial notions of race and in so doing, reinforce longstanding patterns of domination and inequities” (Reimer Kirkham & Anderson, p. 5). For example, higher rates of suicide and substance use are explained as “cultural” problems of particular groups, rather than as consequences of systematic inequities and discrimination. In these “culturalist” explanations, race often operates in tandem with culture as a silent subtext (Reimer Kirkham & Anderson, p. 5). More insidiously, conflating culture with racialized³ characteristics, masks discrimination and inequity with more neutral terminology (Browne, 2007; Goldberg, 1993) and the perceived “inferiority” of the Other becomes normalized and naturalize⁴ (McConaghy, 2000). Drawing on Anderson and Reimer Kirkham (1999), one of the definitions that we continue to turn to defines culture as:

located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes. It is not therefore reduced to an easily identifiable set of characteristics, nor is it a politically neutral concept (p. 63).

Culture is dynamic, it is a relational concept.

Recently, a discussion of relational approaches has been growing in the nursing and the other health care literature. This approach 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 by 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 etc.; although interpersonal connections are a central feature of excellent relational practice, this view takes into account “how capacities and socioenvironmental limitations” influence health and well-being, the illness experience, decision-making and the ways in which people manage their experiences (Browne, Hartrick Doane, Reimer, MacLeod & McLellan, 2010). Thinking critically about how culture is being discussed and integrated into mental health and addictions services is particularly warranted given the tendency in health care for culture to be used in ways that run the risk of masking social and structural inequities that influence well-being, health and health care and illness and other experiences. In our view, the concept of cultural safety holds promise in this regard because it can orient mental health providers and planners, and funders of mental health and addictions services toward relational understandings of culture, and culturally meaningful services and programs.

In the late 1980s, the concept of cultural safety emerged out of concern with structural inequities by Maori nurse educators and leaders within Aotearoa/New Zealand (Anderson et al., 2003; National Aboriginal Health Organization (NAHO), 2008; Papps & Ramsden, 1996; Ramsden, 1990; 2000); in this context, cultural safety was used to foster an understanding of the relationship between minority status and health status as a means of changing health professionals’ attitudes from those that continued to support current dominant practices and systems of health care to those that would be more supportive of the health of Indigenous and minority groups (NAHO; Polashek, 1998; Ramsden, 1993, 2000; Wepa, 2005). In a Canadian context, in keeping with its roots, several researchers have taken up the concept of cultural safety as a critical lens to examine unequal power relations and the social and historical processes that organize these relationships (e.g., Browne et al.,2009; Smye & Browne, 2002;Walker, 2009). The notion of culture in cultural safety is used to address the relationalaspect of Aboriginal peoples’ lives, i.e., among people and between people and their contexts, including the broader social, historical and political realities that shape health care experiences of Aboriginal people. The notion of safety assists us to focus on risk and benefit – e.g., we might ask, ‘Do strategies and interventions aimed at supporting Aboriginal people to address mental health and addictions issues fit with the unique experiences of Aboriginal people?’; and/or Are Aboriginal people who enter mental health and addictions services effective and safe in those settings given the realities of Aboriginal their everyday lives?’; and/or ‘Will the individual and/or family qualify for housing supports given their Aboriginal status?’

In Aotearoa/New Zealand, cultural safety was designed to draw attention to the power imbalances between Maori and the dominant health care culture, which historically disregarded the illness and health belief systems of Maori and instead privileged those of the Pakeha or White culture (Ramsden, 1990; Ramsden, 1992; Ramsden, 1993). Under the premise that cultural safety in clinical practice would improve health outcomes for Maori, the Nursing Council of New Zealand formally adopted cultural safety into nursing curricula and state examinations for nurses and midwives in 1992 (Nursing Council of New Zealand, 2005). Since then,cultural safety has continued to be a powerful nursing concept (Wepa, 2003; 2005) but scholarly contributions from other fields, such as medicine (e.g., Crampton, Dowell, Parkin, & Thompson, 2003; Indigenous Physicians Association of Canada (IPAC) & The Association of Faculties of Medicine of Canada (AFMC), 2009; Kearns, 1997; Nguyen, 2008), occupational therapy (e.g., Gray & McPherson, 2005; Jeffery, 2005; Nelson, 2007), physiotherapy (e.g., Haswell, 2002; Main, McCallin, & Smith, 2006), social work (e.g., Fulcher, 2001; Fulcher, 2002) and pharmacy (e.g., Stoneman & Taylor, 2007), show that cultural safety has permeated a spectrum of health and social disciplines in many parts of the world.

Although cultural safety as originally conceptualized by Ramsden (1990) is based on the notion of biculturalism (Maori and non-Maori), several authors convincingly assert that the concept of cultural safety also retains significance for multicultural contexts given that the experience and effects of colonization on health transcend geographical and political boundaries (e.g., Anderson et al., 2003; Reimer Kirkham, Smye, Tang et al., 2002). Other scholars have explored its applicability to the health care contexts in the United States (e.g., McCubbin, 2006) and the United Kingdom (e.g., Cortis, 2008; De & Richardson, 2008; Hart, Hall, & Henwood, 2003). However, the majority of international scholarly contributions originate from Australia and Canada. In contrast, within Canada, cultural safety has been taken up in various ways in health discourses affirming the transportability of cultural safety to a multicultural policy context.However, while cultural safety has been applied across diverse populations and social groups (Anderson et al., 2003; Baker, 2007; Ogilvie, Burgess-Pinto, & Caufield, 2008), the primary focus in Canada has been on cultural safety in relation to Aboriginal health care (Barkwell, 2000; Browne & Smye, 2002; Browne & Varcoe, 2006; Browne, 2003; Dion Stout & Downey, 2006; Jensen-Ross, 2006; MacLeod, Browne, & Leipert, 1998; Smye, 2004; Smye & Browne, 2002; Smye et al., 2006;).

Advocacy for the implementation of cultural safety into health education and clinical practice reaches from national Aboriginal health and political organizations to professional associations to government. For example, both the Assembly of First Nations (AFN) and the NAHO officially endorse the practice of cultural safety by health care professionals as a means to improve the health status of First Nations, Inuit and Métis (AFN; NAHO, 2008). In addition, Canada has undertaken several critical steps toward moving cultural safety into education. In 2008, NAHOreleased a guide for health care administrators, providers and educators, which provides a working definition of culturally safe practice and programming. Likewise, in partnership with the Association of Faculties of Medicine of Canada (AFMC), and the Canadian Association of Schools of Nursing (CASN) and Canadian Nurses Association (CNA), the Indigenous Physicians Association of Canada (IPAC) and the Aboriginal Nurses Association of Canada (ANAC) have generated frameworks for medical and nursing curricula to teach students and faculty how to build competency in cultural safety (ANAC et al., 2009; IPAC & AFMC, 2009). These efforts are supported by Health Canada through a five year Aboriginal Health Human Resources Initiative (AHHRI) (2005/06-2009/10), which provides funding to increase, and retain the number of post-secondary educational institutions with cultural safety curricula (ANAC et al., 2009; Chiefs of Ontario Office (COO), 2008).

In keeping with this movement, the concept of cultural competence has been taken up alongside cultural safety as a means of achieving cultural safety. The Canadian Nurses Association (CNA) (2004) is thinking about cultural competence as an “application of knowledge, skills, attitudes and personal attributes required by nurses [health care professionals] to provide appropriate care and services in relation to the cultural characteristics of their clients” (p. 1). Similar to cultural sensitivity, cultural competence includes valuing diversity, knowing about the cultural mores and traditions of the populations being served, and being sensitive to these while caring for a client. However, it also has been used to consider the broader context of health and healthcare (Spector, 2004) and, in Canada, to draw attention to power relations and dynamics and to consider culture in ways that directly address issues of racism and inequity (Srivastava, 2007). Currently, many health professional organizations and health institutions and agencies are incorporating the notion of cultural competence into Canadian healthcare settings (e.g., British Columbia Provincial Health Services Authority (PHSA), 2009; CNA, 2004; Canadian Registered Nurses Association of Nova Scotia (CRNNS), 2006). However, health professionals always need to be aware and cautious of the limitations of brief diversity or cross-cultural training programs that fail to address the structural and power inequities that affect healthcare and health (Browne & Varcoe, 2009) – those training sessions that focus the attention of the practitioner on the values, beliefs and practices related to the ‘culture of the Other,’ rather than beginning with relational understandings of culture and self-reflection.

² Culturalism refers to the process of viewing people through the lens of culture, defined narrowly as shared values, beliefs and practices (Browne et al., 2009b). In the case of Aboriginal people, ‘culture’ thus defined operates as the primary explanation for why groups experience various health, social or economic problems such as, for example, poverty, substance use, low birth weight. This is problematic because the issues of social determinants of health, or the root causes of mental health and addictions, are viewed as necessarily linked to peoples’ culture, when in fact, they are part of the colonial history of Canada, and ongoing inequitable social relations.

³ Racialization refers to ways that people are labelled according to particular physical characteristics or arbitrary ethnic or so-called “racial” categories, and then dealt with in accordance with beliefs related to those labels (Agnew, 1998; Ahmad, 1993, p. 18, 19). For example, racialization occurs when health care professionals erroneously assume that alcoholism is somehow a “genetic” feature among Aboriginal people.

⁴ Generally, cultural sensitivity is the practice of being sensitive to the values, beliefs, and practices of all people—a sensitivity that requires a recognition of difference and active engagement to provide care in keeping with that recognition (Smye, in press). However, because cultural sensitivity is most often tied to a notion of ‘culture’ as individual or group values, beliefs, and practices, it fails to address social and structural factors that shape well-being, health and health care (Hartrick Doane & Varcoe, 2005, p. 310). Culturally sensitive approaches run the risk of generating a cookbook response to cultural differences, which can do more harm than good; for example, practitioners learn about the values, beliefs, and practices of “others,” such as “Muslim” values,” “Aboriginal beliefs,” or “Chinese practices” (Smye, in press). – there is a danger that assumptions, stereotypes and generalizations about the “cultural other,” that are often based on race, class, gender, sexual orientation, ability, religion, age, and so on, will be perpetuated (Hartrick Doane & Varcoe, p. 310; as cited in Smye, in press)

Section 2.0: Historical and Present Context: The Need for Cultural Safety

2.0 Introduction

Despite longstanding evidence for the disproportionately higher mental health burden carried by First Nations, Inuit and Métis communities (Royal Commission on Aboriginal Peoples (RCAP), 1995, 1996a, 1996b, 1996c; Canadian Institute for Health Information (CIHI), 2004, 2009), mental health and addictions remain a pressing issue facing many Aboriginal peoples in Canada (The Standing Senate Committee on Social Affairs, Science and Technology, 2006; Romanow, 2002). To engage in any meaningful discussion about Aboriginal mental health in Canada, it is critical to adopt a contextualized and historical approach that reflects a recognition of the aftermath and continued effects of colonization. There is a significant body of work by indigenous and non-indigenous researchers and scholars that speaks to the ways persistent disparities in mental health are entrenched in the history of relations between Aboriginal peoples and nation state colonization (e.g., Adelson, 2005; Dion Stout, 1996, 1997, 2003; Dion Stout, Kipling & Stout, 2001; Kelm, 1998; Kirmayer, Tait & Simpson, 2009a; RCAP, 1995, 1996b; Smye, 2004; Smye & Mussell, 2001). Firstly, colonization, systematic oppression and neo-colonial forces of discrimination and institutional racism have threatened almost every aspect of Aboriginal identity – individually, as well as collectively. Secondly, persistent mental health inequities cannot be understood in isolation of the background of colonial relations that continue to shape access to health care, health care experiences, and outcomes (Browne, Smye & Varcoe, 2005; Browne, Smye, & Varcoe, 2007; Browne & Varcoe, 2006; Smye, 2004; Smye & Browne, 2002; Smye, Rameka & Willis, 2006).

2.1 Impact of Colonization on Mental Health and Addictions for Individuals, Families and Communities

A century of colonial relations and neo-colonial forces including discriminatory and assimilationist government policies have taken a serious toll on the mental health of Aboriginal peoples in Canada (Brasfield, 2001; Browne, McDonald & Elliot, 2009; Kirmayer et al. 2003; Kirmayer et al. 2009a, McCormick, 2009; RCAP, 1995, 1996a, 1996b, 1996c; Smye, 2004). Drawing on the experience of psychologists and other mental health professionals, Waldram (1997) writes that the long-term trauma “that flows from colonialism and oppression” has had profound consequences for both “individual and collective behaviour” (p.43). For example, the social, political and cultural breakdown of Aboriginal communities can be directly linked to the assimilationist interventions and government control under the legal relations established by the Indian Act, 1876 (RCAP, 1996b; Smye; Waldram et al., 2006) and is considered to be the leading cause for the alarmingly high rates of suicide, depression, anxiety, substance use and despair in Aboriginal populations today (Brant, 1993; Kirmayer et al., 2003; Kirmayer et al., 2009a). The assimilationist agenda of the Act was pursued at many levels and gradually took control of most aspects of Aboriginal lives. For example, whole nations were forced to give up their traditional lands and self-government; residential schools were instituted with the goal of indoctrinating children into the dominant culture; and ceremonial and traditional practices that were integral to Aboriginal social, political and cultural life were outlawed⁵ (Kelm,1998; Kirmayer et al., 2003; Kirmayer et al. 2009a; RCAP).

Residential schools and boarding homes have been the most cited cause of the mental health concerns of Aboriginal peoples (Chrisjohn & Young, 1997; Fournier & Grey, 1997; Kelm, 1998; RCAP, 1995, 1996b; Smye, 2004; Waldram et al., 2006; Waldram, 1997; Wade, 1995). Although residential schooling was not uniformly negative for all people⁶, its overall impact has been devastating. Under compulsory residential school attendance, in many instances, Aboriginal children were forcefully taken away from their families to be subjugated to an institutional Christian regime that fiercely suppressed and punished any expression of Aboriginal culture, including the right to speak their native language (Kelm). In addition, many former residential school survivors report on the high prevalence of emotional, sexual and physical abuse that occurred within these institutions (Chrisjohn & Young; Wade). It is estimated that approximately one million children and in some instances, as many as five consecutive generations of children attended residential schools (Wade), for example, the last school in British Columbia was closed as late as in 1984 leaving behind about 35,000 British Columbian residential school survivors (RCAP, 1996).

As Kirmayer et al. (2003) note, the residential schools have “had profound effects on Aboriginal peoples at every level of experience, from individual identity and mental health, to structure and integrity of families, communities, bands and nations” (p. S18). On the individual level, narratives and life histories of residential school survivors suggest that former residential school students endure long-term psychological and social problems that manifest in the loss of individual and collective self-esteem and self-respect, internalized racism, substance use, suicide and a detachment to others, their families and cultural communities (Brasfield, 2001; Kirmayer et al., 2003; 2009a; Söchting, Corrado, Cohen, Ley, & Brasfield, 2007). In fact, Brasfield notes that in addition to a specific cultural impact, many residential school survivors experience symptoms that are characteristic of post-traumatic stress disorder (PTSD), such as “recurrent intrusive memories, nightmares, occasional flashbacks, and quite striking avoidance of anything that might be reminiscent of the Indian residential school experience” (p.79).

On the societal level, residential schools have had trans- or inter-generational effects on the Aboriginal community as a whole (Kirmayer et al. 2003; 2009a; RCAP, 1996b; Waldram et al., 2006; Waldram 1997; Wade, 1995, Warry, 1997). As Smye (2004) writes, the loss of: i) attachment to community and the relationships of trust built there; ii) cultural values and norms which provided a sense of cultural identity including language and spirituality; iii) life skills usually taught by parents, elders, and other community members; for example, parenting skills; iv) self-identity, for example in one’s creative abilities; and v) health and in some cases life, has scarred many Aboriginal communities and is implicated in the disproportionately large proportion of Aboriginal children in care⁷ (Kelm,1998; Blackstock, 2005; Blackstock & Bennett, 2003) and Aboriginal people in federal and provincial prisons across Canada (Monture-Angus, 2000; Waldram). This is particularly concerning given that it is well known that children who are apprehended by the Child Welfare System and placed in foster families, often grow up with very similar experiences as their parents under the residential school system (Kelm, 1998); are more likely to become involved in the correctional justice system; and, less likely to complete high school (Browne et al., 2009a).

In assessing the mental health of Aboriginal people in Canada, transplantation and consequent sedentarization⁸ are also important historical considerations. As Samson (2009) notes, “since their sedentarization, the Innu who were settled in the Labrador villages have suffered extremely high rates of suicide, alcohol abuse, solvent abuse and sexual abuse. The Inuit also have experienced profound changes in their lifeways in just two to three generations –mandatory schooling and social housing regimes have severely disrupted childrearing practices and family coherence for many Inuit (Kirmayer, Fletcher & Watt, 2009b).

The pervasiveness of poverty casts a similar shadow over the lives of Aboriginal peoples. Economic marginalization and welfare colonialism have resulted in a high degree of unemployment, a high degree on meagre social assistance payments (Fiske, 1992) and low incomes relative to other Canadians, making poverty endemic to many Aboriginal communities in Canada. For example, although income is gradually improving across First Nations peoples, First Nations’ educational attainment and employment still considerably lag behind rates from the general Canadian population (First Nations Centre, 2007). Although there is a tremendous variability across First Nations communities, on most reserves despair is heightened by a lack of economy, inadequate educational facilities and shortage of housing (Smye, 2004; Browne et al., 2009a). Among Aboriginal people in Census Metropolitan Areas (CMAs), 41.6% were living in low income, more than double the national average for CMAs. As with lone parents and recent immigrants, Aboriginal people represented a disproportionately large share of the low-income population (Heisz & McLeod, 2004).

Today, poverty, employment and housing are identified as key social determinants of Aboriginal mental health with some researchers calling the high Aboriginal suicide rates indicators of community need (Cooper, 1995; British Columbia Provincial Health Officer (BC PHO), 2002; RCAP, 1996b). Poverty undermines self-esteem and self-worth, making people more vulnerable to alcohol and substance use and violence against others and oneself (ANAC, 2002; Dion Stout, 1997). For example, although there are enormous variations across communities, bands, and nations, the overall suicide rate within First Nation communities today is about twice that of the total Canadian population with suicide rates in some Aboriginal communities continuing to rise over the past two decades (Kirmayer et al., 2007). As Kirmayer and colleagues note, suicide is never the result of a single cause, rather is arises from an interaction of social, historical, political and personal factors (p. xv). In addition, as Samson (2009) writes about the Innu – the repercussions of suicide are widespread given that people generally living in small villages and are bound together by strong family ties.

Similarly, violence against women continues at alarming rates. In 2005, Statistics Canada‘s General Social Survey (GSS) reported that rates of spousal assault against Aboriginal women in the previous five years by a current or ex-spouse was more than three times higher (at 24%) than that of spousal assault reported by non-Aboriginal women (Native Women’s Association of Canada (NWAC), 2007). As LaRocque (1996) states, “racism and sexism together result in powerful personal and structural expressions in any society, but they are clearly exacerbated under colonial conditions” (p. 15) making that the alarmingly high rates of domestic and sexual violence experienced by Aboriginal women and children are “one of the most problematic legacies of long-term colonization” (LaRocque, 1993, p. 74). This is particularly concerning given that Aboriginal people who commit suicide are likely to have experienced “higher rates of family and personal alcohol abuse, and/or physical or verbal violence either as a victim or as a perpetrator” (Cooper, 1995, p. 220).

Despite these disparities, it is important to note that many Aboriginal people are doing very well—it is for the more marginalized Aboriginal people that attention is drawn to health inequities and to the need for cultural safety. As this section has attempted to illustrate, the mental health inequities of Aboriginal peoples cannot be glossed over as lifestyle, behavioural, or cultural issues, rather, they are manifestations of the historical, social, political, and economic determinants. 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, p.21). This disrupted the circle of life and left wounds and scars on the bodies and minds of Aboriginal peoples, families and generations to come (RCAP, 1996b; Kelm, 1998). These issues compounded by the lack of mental health and addictions services are pressing issues for Aboriginal peoples in Canada.

⁵ For example, even potlatching was outlawed. Traditionally, this was central to the whole concept of status and rank, and played a pivotal role in the social organization of the community. Because there was no writing system, the potlatch “served to publicly recognize an individual’s claim to a particular status of inherited right. It also served an economic role, redistributing food and goods” (McMillan, 1995, p. 204). Today, potlatching remains an important aspect of community life for many West Coast people, although with somewhat different meanings than in earlier times.

⁶ In her research with Carrier people of north central BC, Fiske (1996) carefully documents how women advanced their social, economic, and political roles within and outside their communities using some of the skills and knowledge acquired in residential schools. In spite of harsh treatment, these women were paradoxically able to build structures of resistance to a system that unintentionally provided them with the tools to do so. She states: “Women (and men) selectively utilized novel skills and knowledge beneficial to themselves. And, in doing so, they effectively subverted the missionaries’ intentions by broadening their economic strategies and by developing sophisticated political responses, which to a large measure were spearheaded by a schooled female leadership” (p. 181)

⁷ Statistics indicate a steady increase of Aboriginal children in care, with a 6% national prevalence rate for 2000. The difficulty with this information is that it only refers to children in care who were living “on reserve” prior to coming into care, and it does not include any data from the North West Territories and Nunavut, any Self-Government First Nations, or First Nations which were not administered under a Child and Family Services Agreement (INAC, 2002). Bennett and Blackstock of the First Nations Child and Family Caring Society, note that “there are approximately 22,500 First Nations children in the care of Canadian Child welfare authorities” today – three times the highest enrollment figures of residential schools of the 1940s (Blackstock, 2003, p. 6). The ability to accurately reflect the reality of the percentage of children in care who are Aboriginal is limited by the differing definitions and methods of calculating total numbers of ‘children in care’, and ‘Aboriginal children.’ Available data suggest a range of 30%-40% of children in care are Aboriginal across Canada (Blackstock)

⁸ Sedentarization involves the settlement of a nomadic group of people into a territory – it is often approached in terms of social (including legal), political, economic and territorial organization.The Innu are the northernmost Algonquian-speaking peoples of North America and have occupied the Labrador-Quebec peninsula for as long as 7,500 years. “Human understanding of this complex northern landscape is given its deepest meaning in Innu history, stories, legends, religion, and language, as well as in their lives as nomadic hunters” (Samson, 2004). However, aggressive systematic dismantling of this way of life was enacted through colonial process and practices of the state of Canada.

2.2 Evolution of Health Services and Consequences for Aboriginal Health

Despite the shifting landscapes of Aboriginal health, mental health and addictions remain pressing issues facing Aboriginal peoples in Canada (The Standing Senate Committee on Social Affairs, Science and Technology, 2006; Romanow, 2002). Increasingly, it is being recognized that mainstream mental health services and programs are not effectual and often inaccessible to Aboriginal peoples (Adelson, 2005; BC PHC, 2002; CIHI, 2004; Dion Stout, Kipling, & Stout, 2001; NAHO, 2002, 2003; Smye & Mussell, 2001). To redress issues of access and effectiveness, it is critical to understand the historical and structural contexts in which mental health care for Aboriginal peoples has evolved.

As a central institution of dominant society, medicine, its perspectives, structures and practitioners, have been instrumental in shaping colonial relations, both within the dominant society through formulations of colonial power, and between the colonizers and their subjects (Kelm, 1998; Smye, 2004; Smye & Browne, 2002; Tait, 2008). The history of forced dependency on services upon former independent nations by Western forces can be directly traced back to the role that Western medicine played during the epidemics that plagued Aboriginal communities upon early contact with non-Aboriginal traders, explorers, and settlers, and the inception of the Indian Act in 1876 (RCAP, 1996a; Waldram et al., 2006). To ensure the survival of their people, Aboriginal leaders entered into agreements and treaties with the state (RCAP),which often offered limited food rations and medical resources⁹ in exchange for economic gain and religious conversion (O’Neil & Kaufert, 1990). However, from the perspective of local governments, the provision of health care to ‘Indians’ was seen as an act of benevolent paternalism and generally took the form of crisis relief (Young, 1984). The construction of Aboriginal people as “diseased savages” in need of being “civilized” and saved provided the moral grounds for these actions.

In 1867, the British North America Act gave legislative responsibility for health care and ‘Indians’ to the federal government. Aboriginal people became “administered people,” “wards of the state,” with a separate branch of the federal government devoted to their affairs (Smye, 2004). Yet, the Act did not obligate the federal government to pay for medical care or provide for doctors and thus, in reality the money followed the settlements of ‘white’ people who held the right to vote (Kelm, 1998). Ultimately, only the necessity to contain the spread of diseases and associated health care costs resulted in a systematic provision of ‘Indian’ health services with paternalistic and authoritarian models of care that legitimized compulsory treatment in segregated facilities (Kelm)¹⁰. Thus, growing demoralization and dependency were reinforced by authoritarian and paternalistic models of health care delivery (Smye) leaving a deep mark on the memories and bodies of many Aboriginal peoples.

Only a decade later, the government introduced the Indian Act (1876), which according to some, formed the basic argument for both the federal and provincial governments to abdicate from part of its responsibility to provide health care to Aboriginal peoples (O’Neil, et al., 1999). This Act “became one of the most divisive and destructive aspects of the Indian Act” (Smye, 2004, pp. 26-27) by dividing Aboriginal peoples into two mutually exclusive categories: the deserving versus the non-deserving “Indian” (O’Neil). Under the Indian Act, the Canadian government imposed “an arbitrary but devastating class structure” on Aboriginal peoples (Smye, pp. 26-27) by legally dividing Canadian Aboriginal peoples into First Nations, Inuit, and Métis and by then only assuming responsibility for the delivery of direct health services to Inuit and registered First Nations.

As Smye (2004) argues, the legal relations established by the Indian Act continue to be fundamental to the tensions and disjunctures that exist between Aboriginal peoples and the mental health and addictions systems of care today. For example, although under contemporary Canadian Aboriginal health policy, health services for First Nations are to be provided collaboratively by regional, provincial and federal governments in partnership with First Nations, the current federal position has only slightly shifted (Hanselmann, 2003a), perpetuating and reinforcing longstanding jurisdictional access barriers to health services for First Nations. In addition, today a First Nations person’s ability to access services is determined by a complex set of questions of ancestry (status or not), place of residence (reserve or not), legislation (provincial and federal), and treaty negotiations (Lemchuk-Favel & Jock, 2004). While status, residence and treaty affect an individual’s ability to access primarily federal Aboriginal-specific services, legislation and geographic jurisdiction affects an individuals’ ability to access provincial services (Browne et al., 2009a). As a result, the health needs and rights of Aboriginal peoples, particularly Métis and urban non-Status First Nations, have often been lost in the jurisdictional struggle of who has responsibility for what population of Aboriginal peoples.

One striking example of how these jurisdictional issues play out on the ground is the Downtown East Side of Vancouver; a community that is known to be the poorest neighbourhood in Canada with the highest concentration of Aboriginal peoples in Western Canada living in this part of the city (RCAP, 1996b). Despite the fact that the health and social conditions of Aboriginal peoples living in this neighbourhood is at least equally poor if not worse than for on reserve residents, they are denied direct access to most federal funds and programs that are available to Status First Nations living on reserve (O’Neil et al., 1999).

Another historical and contemporary source of tension that plays a major role in sustaining inequities in mental health for Aboriginal peoples is the disjuncture between Aboriginal understandings of mental health and the biomedical epistemological assumptions and approaches to mental health care (Browne & Smye, 2002; Josewski, 2009; Smye, 2004). Health care, including mental health and addictions care, has been dominated by biomedicine, liberal individualism, and more recently, corporatism. Although biomedical models are important in health care they are insufficient to understanding and responding to health-related issues because they are tied to conceptions of health as primarily located in individuals, peoples’ physical bodies, and micro-level interactions, thereby leaving unexamined the underlying social and structural dynamics that actually produce health and health inequality ( Weber & Parra-Medina, 2003). Corporatism refers to the primacy of a business model in which the dynamics of the marketplace and management and organizational theories shape health care, and mental health and addictions services, such that that economic and political values dominate (Varcoe & Rodney, 2009). Liberal individualism is the valuing of individuals over the collective that is common to liberal democracies. Individualism has tended to locate the problem of mental health and addictions in individuals, their individual failings, or their inability to engage as active citizens in dominant social processes. These social, ideological, and political forces have shaped the landscape of mental health and addictions services – with particular consequences for many Aboriginal people.

Under colonial relations, Indigenous practices including traditional forms of healing were viewed as unscientific superstition and replaced by a medicalization discourse that was part of the predominant Western paradigm (Smye, 2004), a perspective that continues to contour contemporary mental health reform in Canada (Morrow, 2004). For example, the key guiding policy document of BC’s most recent mental health reform, the 1998 Mental Health Plan Revitalizing British Columbia’s Mental Health System, states that “mental illness represents a diseased state of the human brain and not just disadvantaged social conditions” (p.58) and as such, “require[s] medical treatment” (BC. Ministry of Health and Ministry Responsible for Seniors, 1998, p.26). As a result, the 1998 Mental Health Plan falls short on addressing the majority of mental health issues experienced by Aboriginal peoples as well as their socio-political and historical root causes because it is only designed to address quality of care issues related to peoples with serious and persistent mental illness, such as schizophrenia and bipolar disorder as defined by the DSM-IV (Smye & Browne, 2002; Smye, 2004). Similarly, the Romanow Report (Romanow, 2002) continues to narrowly define access issues for Aboriginal people in terms of insufficient supply and distribution of health care providers while, at the same time, BC’s Mental Health ‘Best Practices’ documents (2002) have been criticized for their omission of a critical cultural lens and its biomedical ideological underpinnings that continue to define mental health issues and treatment in individualistic terms (Smye & Mussell, 2001). Indeed, “the relational language of an Aboriginal worldview generally is missing from the ‘Best Practices’ documents” (Smye & Mussell, p. 29).

More recently, other documents, such as the Kirby Report (The Standing Senate Committee on Social Affairs, Science and Technology, 2006), adopts a more critical lens supporting the call by Aboriginal key leaders for a holistic and comprehensive wellness strategy for mental health and addictions. The Kirby Report is of particular significance because it resulted in federal support for the establishment of the Mental Health Commission of Canada (MHCC) in 2007, which is intended to guide mental health reform nation-wide. However, although the Canadian government followed Kirby’s recommendation to establish the Commission, in response to advocacy for the separation of mental health and addictions led by a national group on addictions, addictions was purposively excluded from the mandate of the Commission; this exclusion runs the risk of marginalizing the mental health needs of people who are disproportionately affected by both, including Aboriginal peoples.

Mental 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 (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). They often are not effectual, underused and often 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 (Benoit et al., 2003; Browne, 2005, 2007; Browne & Fiske, 2001; Culhane, 2003; Dion Stout & Kipling, 1998; Dion Stout et al., 2001; RCAP, 1996; Smith et al., 2006; Smith et al., 2005; Tang & Browne, 2008; Varcoe & Dick, 2007, 2008). As Browne et al. (2009a) point out, “these findings remind us that the micropolitics of health services delivery cannot be separated from the socio-political and historical contexts in which they occur” (p. x).

In response to the above challenges, Aboriginal peoples have been seeking responsibility for administering and controlling their own health programs with the belief that “true community healing and well-being can be found only through self-government and self-determination” (O’Neil et al., 1999, p. 149). A major contributor to building a vision on what healing for Aboriginal Peoples in Canada would look like was the work of the 1996 Royal Commission on Aboriginal Peoples. After extensive community consultation, the Commission published its final report five years after its creation. The following key principles and values identified for healing remain progressive ideas for Aboriginal health policy today and are consistent with Aboriginal perspectives articulated in the 2001 Provincial Health Officer’s Annual Report on the Health and Well-being of Aboriginal Peoples in British Columbia and the recent report on Canada’s mental health care system by Senator Kirby (The Standing Senate Committee on Social Affairs, Science and Technology, 2006; BC PHO, 2002):

Adoption of a formal commitment to improve Aboriginal Health;
Recognition of the issues and challenges faced by Aboriginal peoples;
Support for Aboriginal self-determination and control;
Fostering of greater participation of Aboriginal peoples in designing, delivering and governing of programs;
Improvement of the social determinants of health, such as economic prospects and housing; and
Promotion of culturally appropriate, holistic approaches to health.

Thus, within the Indigenous health movement, the inclusion of Aboriginal voices in mental health care programming and delivery is imperative for improving Aboriginal health, and overcoming system-related barriers to access and to incorporating the element of choice for Aboriginal healing, if so desired. However, while Aboriginal self-determination is central to the Canadian Indigenous movement, it manifests differently for on- and off- reserve Aboriginal communities. On reserve, the primary mechanism for communities to increase self-governance is different degrees of health transfers. In contrast, urban communities are deprived from this right. Instead, for off reserve Aboriginal service providers and organizations, the notion of Aboriginal self-determination is engrained in the discourse of increased participation and shared decision-making power in health policy and practice. However, little real empowerment of Aboriginal communities may be occurring due to inconsistencies in transfer arrangements (Fleras & Elliot, 1992), the need for program enrichment (O’Neil & Postl, x) and notoriously scarce and short-term funding for Aboriginal mental health and addictions programs on- and off-reserve (RCAP, 1996b; Josewski, 2009). These constraints intersect with political economic interests that promote reduced expenditures on social programs, increased push forprivatization as well as a shift towards self-management (Morrow, 2004). Over the past decade, for example, cost containment in health and social sectors has been paramount in the organization and delivery of health care services (Anderson, 2000; Burgess, 1996; Evans, 1992; Morrow, 2004; Morrow, Frischmuth & Johnson, 2006; Storch, 1996; Varcoe and Rodney, 2002). As one of the most vulnerable populations in Canada, the residents of Aboriginal communities are particularly sensitive to the consequences of downsizing and other cost-cutting measures in the health care system (O’Neil et al., p. 148), including the threat it poses to Aboriginal autonomy (Smye, 2004).

Nevertheless, Aboriginal peoples have achieved some significant accomplishments in negotiations with both federal and provincial governments in recent years. For example, following the recommendation of the Kirby report (The Standing Senate Committee on Social Affairs, Science and Technology, 2006), in 2007, the federal government established a First Nations, Inuit and Métis Advisory Committee to the Mental Health Commission of Canada (MHCC), chaired by William Mussell, a Stó:lō First Nations man from British Columbia and Chair of the Native Mental Health Association of Canada. This Advisory Committee is “dedicated to promoting overall mental health and reducing the threats to well-being among Indigenous people living in communities on and off reserves in Canada” (MHCC, 2009). In addition, there are other First Nations, Inuit and Métis members on several of the other sub-Committees of the Commission and one of the five Chairs of the Commission is Madeleine Dion Stout, a Cree speaker and esteemed nurse scholar in Canada who has expertise in Aboriginal health, including suicide prevention and Aboriginal women and violence. Yet, progress in the area of Aboriginal health in Canada is rather erratic and characterized by many tensions as illustrated by Canada’s recent refusal to sign the Declaration on the Rights of Indigenous Peoples adopted by the United Nations (UN) in September 2007.

⁹ Aboriginal medicine was not supplanted by Western approaches; rather, a state of medical pluralism developed in which Aboriginal peoples drew on both Aboriginal and Western medicine to deal with new diseases (Kelm, 1998). Throughout the first decades of contact, early settlers availed themselves of Aboriginal substances and medicines and Aboriginal peoples built medical systems that incorporated new remedies while “maintaining an indigenous base of medical thought” (Kelm, p. 153). However, it was the processes of colonization, complete with systems of thought that excluded Aboriginal forms of medicine asquackery or superstition, that stifled the cross-cultural exchange (Kelm, p. 153).

¹⁰ For example, even today, “the question of whether a treaty right to free, comprehensive medical services exists for Status Indians is one of the most controversial areas of Aboriginal health care” (BC Ministry of Health Planning, 2002, p.

2.3 What works well

Cultural discontinuity has been strongly linked to the disproportionate problems of Aboriginal communities with depression, addictions, suicide and family violence (Chandler & LaLonde, 1998; RCAP, 1995). According to a public opinion poll in 2002, 63 percent of Aboriginal participants reported that cultural discontinuity and loss of land have had a significantly negative impact on their health (Assembly of First Nations & Social Development Department, 2005). Reversely, studies 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).

According to Brant Castellano (1999), “the healing process gains strength from many sources, but principally from rekindled confidence in traditional wisdom and a political-historical analysis of the genesis of present distress” (p. 95). As Kirmayer, Brass and Valaskakis (2009c) note, notions of tradition and healing are fundamental to the mental well-being of Aboriginal peoples – to address the legacy of colonization through “community-based initiatives and larger political and cultural processes” (p. 440). As such, there has been a resurgence of traditional ways of healing and healing concepts among Aboriginal communities. The Aboriginal Healing Foundation (AHF) was established in response to recommendations of the Royal Commission on Aboriginal Peoples¹¹ “to support healing projects that would address the transgenerational effects of the residential schools” Kirmayer et al., p. 453) and analysis of the projects funded by the AHF suggests the importance of addressing historical trauma experienced by Aboriginal people (e.g., the aftermath of the residential school experience) – an important step in the process of individual and collective healing (Brant Castellano, 2006; Stout, 2003, as cited in Kirmayer et al., p. 455). However, although analysis of the projects of the AHF has demonstrated their importance, recently the AHF faced the threat of serious funding cuts by the federal government with potential far-reaching consequences (CBC, March 15, 2010). Aboriginal mental well-being continues to be seriously challenged by continued unstable funding arrangements and often a lack of political good will.

Under the conditions of colonization, Aboriginal systems of medicine were disrupted, delegitimated and challenged through new infectious diseases and Western forms of medicine. However, they did not disappear. “Aboriginal ideas about the body, disease, and medicine, then, were not just remnants of some pre-contact past but were living ways of viewing the world” (Kelm, 1998, p.84). 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). “Holism (as Aboriginal peoples use the term) means sensitivity to the interconnectedness of people and nature, of people and their kin and communities, and within each person, of mind, body, emotions and spirit” (RCAP, 1995, p.83). Family as an institution is central to Aboriginal culture and many Aboriginal peoples have argued that rehabilitation of Aboriginal families has to be part of the path to personal and community healing (Mussell et al., 1991). Hence, successful community initiatives distinguished themselves from mainstream services through the high degree of family involvement, a multi-disciplinary team approach and the mobilization of whole-communities under Aboriginal authority (RCAP, 1996b).

In the discussion paper on what works best for Aboriginal communities, the Aboriginal Mental Health “Best Practices” Working Group concludes that community-based initiatives and a balanced approach to mental health including treatment, prevention and health promotion strategies have proven to be more effective than treatment-oriented mainstream services under non-Aboriginal authority (Smye & Mussell, 2001). In addition, findings of analysis of the 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 with an understanding and awareness of intergenerational impacts of the residential school system and other aspects of Aboriginal history. Also, included in this framework are ‘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, p. 12).

¹¹ On March 31, 1998, the Aboriginal Healing Foundation was created. It was given a ten-year mandate- one year to set-up; 4 years to disburse the $350-million healing fund on a multiyear basis, and 5 years to monitor and evaluate the projects (AHF, Summary of Final Report, on-line).

Section 3.0: What Cultural Safety Brings to Mental Health and Addictions Services

3.0 Introduction

As discussed earlier, cultural safety is a relatively new concept that emerged in the New Zealand nursing context, and is being taken-up in various ways in Canadian health care contexts. We argue that cultural safety is particularly relevant to health care contexts in general, and to mental health and addictions services in particular for the following reasons: cultural safety, as we conceptualize it, is compatible with critical perspectives that focus on power imbalances and inequitable social relationships in health care; problems associated with culturalism and racialization in health care; and a commitment to social justice as central to the mandate of health care in Canada (Browne et al, 2009b). We have been using the concept of cultural safety in research and teaching in nursing and medical programs to draw attention to these critical issues; however, less is known about the application of cultural safety in health care contexts, and the services that could be possible if informed by cultural safety. What we have discerned over the years of working with the concept of cultural safety, both in health care, and in university-classrooms contexts, is that cultural safety cannot be easily defined and “neatly packaged” as a concrete set of standards for practice (Browne et al., 2009b; Anderson et al., 2003; Reimer Kirkham et al., 2002; Smye, 2004; Smye et al., 2006). In part, this is because using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge brings an added layer of complexity (Browne et al.). For example, grasping the issues that we conceptualize as core to cultural safety, for example, the need for health care providers to reflect critically on issues of racialization, institutionalized discrimination, culturalism, and health and healthcare inequities in mental health and addictions services requires layers of understanding that are not necessarily translatable into straightforward “practice guidelines.” Understanding of cultural safety requires health care providers (and policymakers) to engage in dialogue regarding the root causes of inequities in mental health and addictions, which creates the potential for discomfort related to a number of issues, including the call to be accountable and actionable. Yet, we argue, that there are fundamental issues that cultural safety draws attention to that are inherently valuable if mental health and addictions services for Aboriginal people in Canada are to be improved. In this section, we consider what cultural safety could bring to health services in the field of mental health and addictions, and what a framework for cultural safety services could look like.

3.1 Prompting Critical Reflection on How the Dominant System of Health Care Affects Aboriginal Peoples

Cultural safety prompts us to reflect on the values and ideologies that influence mental health and addictions services – and simultaneously, to reflect on whether there are new possibilities for conceptualizing and delivery mental health and addictions care. As we have argued, a central feature of cultural safety is critical reflection among health care providers, decision-makers, policymakers, students, educators, and researchers. However, it is important to note that critique or critical reflection is not synonymous with criticism; rather, critique and critical reflection refers to examining the conditions and assumptions upon which something exists (Reimer Kirkham et al., 2009). Such distinctions are important if health planners and policymakers are to engage meaningfully with the notion of critical reflection and critical inquiry with a view to improving the dominant system of care.

At its most basic, cultural safety would prompt reflexivity in the area of mental health and addictions services – it would involve practitioners holding up for scrutiny their own and others’ knowledge claims, taken-for-granted assumptions, and practices (Taylor & White, 2001, p. 55). When considering the knowledge claims, perspectives, or assumptions of colleagues, you can apply similar questions and look for ways to engage in dialogue. Dialogue in health care delivery settings is central to the process of reflexivity, and in many cases, this may involve a tolerance for the discomfort of questioning usual practices in mental health and addictions. Aultman (2005) for example, calls for a “pedagogy of discomfort” in which students think critically about the various values that underpin peoples’ perceptions of the health care system, and providers’ and the system’s responses to people (p. 263).

Cultural safety, because it draws attention to relational understandings of culture, can be used to question what premises and intentions are at the heart of the ongoing calls for “cultural sensitivity”¹² training and programming in mental health and addictions. As noted earlier in this paper, from the perspective of cultural safety, we understand culture as a relational aspect of ourselves that shifts over time depending on our history, our past experiences, our social, professional and gendered location, and our perceptions of how we are viewed by others in society (Browne & Varcoe, 2006; Smye, 2004; Smye, Rameka & Willis, 2006).

Simultaneously, because cultural safety reinforces relational understandings of culture, it can also help those who are working in mental health and addictions with Aboriginal people to appreciate how discourses about culture can be (and ought to be) interpreted and mobilized in many different ways for different purposes (Browne & Varcoe, 2006). For example, in the context of mental health and addictions services, claims about the importance of cultural considerations in programming may be essential for justifying claims for improved access to services, increased funding targeted to particular populations, or to illuminate inequitable practices that affect groups of patients in particular ways. In Canada, for example, it is critical for Aboriginal organizations concerned with mental health and addictions services to argue that residential schooling and intergenerational trauma have had a deleterious effect on Aboriginal culture, so that appropriate healing programs can be designed and funded, and so that organizations can claim their right to program funds (for example, programs through the Aboriginal Healing Foundation). Making claims about the cultural damage incurred as a result of many peoples’ shared experiences at residential schools can be understood as using one’s cultural positioning for strategic purposes. From a relational understanding of culture, and from the perspective of cultural safety, these can be appreciated as legitimate claims which ought to be heeded in order for past inequities to be redressed.

At a structural level, cultural safety can be used to draw our attention to those aspects of mental health and addictions policies that do not fit for Aboriginal peoples. For example, some of the key perspectives and understandings that underpin the goals of the Commission might not necessarily fit neatly with the perspectives underpinning the MWAC strategic action plan, i.e., the commitment to the centrality of culture and the role of holistic strategies; addictions understood as inextricably tied with mental health [well- being]; healing and recovery as linked and understood from a wellness perspective rather than beginning from an illness perspective; and the valuing of community-based practices and a coordinated continuum of services, from prevention to aftercare.

¹²Cultural sensitivity tends to be attached to notions of ‘culture’ that limit culture to the values, beliefs and practices of the other person. Although this is not always the case, generally, cultural sensitivity does not address the context in which well-being, health and illness occur – to the social, political, historical and cultural factors that shape well-being, health, illness and health care.

3.2 Creating Ethical Spaces of Engagement in Mental Health and Addictions Care

As Caroline Tait (2008) argues:

Individuals who are mentally ill, distressed, or struggling with addiction are among the most vulnerable in any Aboriginal community. However, in addressing their needs, Western medical models of diagnosis and treatment marginalize the historical and social context of their suffering, the social inequities that exacerbate their distress, and the inner strengths and resilience of Aboriginal peoples and their cultures to survive despite ongoing adversity (p. 30).

Drawing on Ermine’s notion of “ethical space,” Tait (2008) suggests that ethical standards informed by the concept of cultural safety have the potential to inform the development of prevention, promotion, and treatment programming in the area of mental health and addictions involving Aboriginal people.

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) – in this case, inequities in access to, and ways of addressing, mental health and addictions services involving Indigenous people in Canada. Cultural safety, with its focus on shifting the gaze from the ‘culture of the Other’ onto the ‘culture of health care’ as the source of the problem, is helpful for examining the extent to which mental health and addictions services for Aboriginal people are founded on Eurocentric and Western biomedical premises that undermine attempts to transform the “best practices” that could more optimally and explicitly benefit Aboriginal people (Ermine, 2005). As Tait reminds us, the problem of transforming mental health and addictions services lies not with individual front-line workers, but rather within the larger bureaucratic and health system structures within which programs, policies and services are designed and delivered. As Smye and Browne (2002) write, these questions include, for example, do current mental health services fit well with Aboriginal understandings, illness and healing, or are they at odds with them given the current sociopolitical environment? How are the myriad social issues such as poverty and homelessness, that serve to curtail the life opportunities of many aboriginal people, and, as such, their health, being addressed? (p 47)

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 historical and contemporary adversity” (Tait, 2008, p. 32).

In an earlier paper that explored the relevance of cultural safety in the context of mental health reform in Canada, it was argued that the concept of cultural safety could be used to ask a series of moral questions about the “rightness” of policy decisions (Smye & Browne, 2002). We extend that argument to suggest that cultural safety can be used within the framework of ethical space to prompt questions related to service delivery in the field of mental health and addictions. In particular, we suggest that the concept of cultural safety can be used as a framework for assessing whether the values that underlie service delivery (at the organizational level, and at the level of provider-client interactions) are aligned with the ways services are organized and delivered.

One of the central features of integrated, culturally safe approaches to mental health and addictions services is explicit attention to what is valued as: (a) the causes and conditions that give rise to mental health and addictions issues, and (b) what are valued as approaches to treating/addressing mental health and addictions issues with individuals, families and communities. For example, if what is valued is explicit acknowledgement of the socio-political and historical causes and conditions that have resulted in disproportionately high mental health and additions issues, then services delivery would be organized in ways that reflect that understanding. Similarly, if what is valued are approaches to service delivery that acknowledge the impact of trauma¹³ – meaning, historical, intergenerational, emotional, physical trauma –integrated services may be more highly valued (and resourced). By integrated services, we mean services that include interdisciplinary teams of skilled elders, community outreach workers, trauma counsellors, specialists in chronic pain, residential school healing circles, psychological services, social workers, housing services, etc.

How might this be operationalized at the practice level of service delivery? One way would be to ensure that mental health and addictions services are provided from a stance that acknowledges the historical trauma and family dislocation that is often at the root of mental health and addictions issues. Another approach would be to always frame mental health and addictions issues in relation to the contextual features of peoples’ lives – by contextualizing addictions and mental health issues in a wider historical context, as one example, and responding with a wide range of services that could be offered, versus viewing those issues from an individualistic perspective.

At the organizational level, providing integrated mental health and addictions services that align with espoused values requires a commitment to recruit Aboriginal and non-Aboriginal staff who are committed to, and can enact, a particular philosophical approach to service delivery. Given the health human resource shortage in Canada, and the relatively few health care providers and mental health and addictions workers who are of Aboriginal descent in the Canadian workforce, it will be challenging to recruit Aboriginal staff. However, what remains exceedingly important is to recruit staff whose values align with the wider context of mental health and addictions issues as they affect Aboriginal people, families and communities and to provide educational and training opportunities for Aboriginal people interested in this area of focus.

¹³ In this report, we are conceptualizing trauma broadly as inclusive of historical trauma, trauma resulting from structural violence, intergenerational trauma (e.g., residential school traumas), and the effects of physical trauma and violence.

Section 4.0: Recommendations and Conclusions

4.1 Engaging cultural safety as a concept for working toward social justice in Mental Health and Addictions Care

Because it has been derived from experientially grounded reflection by nurses rather than from academic theorizing (Polaschek, 1998) cultural safety has been subject to ongoing theoretical and methodological criticism (Ramsden, 2000; Johnstone & Kanitsaki, 2007a; Johnstone & Kanitsaki, 2007b). As a result, proponents have continued to redefine cultural safety while maintaining the overall significance of cultural safety for moving toward transformative change and social justice (Anderson et al., 2003; Browne et al., 2009; Kirkham et al., 2002; Papps & Ramsden, 1996).

Although cultural safety is a concept that has clear applications to the field of mental health and addictions, there are a few cautions that we wish to highlight. As we continue to work with the concept in the context of Canadian health care services, we are increasingly aware that the label, ‘cultural safety’ is open to considerable ambiguity in interpretation – and often misinterpretation (Browne et al., 2009b). Cultural safety, as we have conceptualized the concept, requires explicit attention and understanding of several key issues that are at its core – for example, the need for health care providers, policymakers, and organizations to reflect critically on issues of racialization, institutionalized discrimination, culturalism, and health and health care inequities, and the root causes and conditions that give rise to mental health and addictions issues among Aboriginal populations. Without explicit commitment to grapple with these issues – the emphasis on ‘culture’ in the term ‘cultural safety’ runs the risk of misinterpretation.

In large part, the tendency for the notion of culture in cultural safety to be taken up in misinformed ways is related to the predominance of culturalist discourses in Canada. As Browne et al, (2009b) have argued,

Without a solid understanding of how culture itself is conceptualized in cultural safety, the risk lies in unintentionally implying that what is needed is more cultural knowledge – with cultural knowledge typically narrowly interpreted in culturalist terms as the values, beliefs, and customs that are assumed to be inherent to particular groups of people (p. 173).

We argue that the concept of cultural safety cannot be used without first fostering an understanding of the critical conceptualization of culture that is foundational to the concept of cultural safety. As noted earlier in the paper, this includes firmly grounded applications of cultural safety in an understanding of culture as a dynamic, power laden process created by people in relation to one another, their environments, and sociopolitical and historical contexts – as relational (Anderson et al., 2003; Browne & Varcoe, 2006; Doane & Varcoe, 2005; Lynam et al., 2007; Reimer Kirkham et al., 2002; Smye & Browne, 2002). Otherwise, cultural safety can convey that the safety to be ensured is that of the ‘cultural Other,’ at once further entrenching notions of difference, focusing on individual ‘preferences’ and turning attention away from the importance of reflexivity on the part of the health care professional (Browne et al., 2009b). These are significant risks to consider given that the rationale for using the concept of cultural safety is to prompt transformative shifts in mental health and addictions services, and more broadly, in the culture of health care (Ramdsen, 2000).

Even in New Zealand, where cultural safety is part of the lexicon in nursing and medical education, it has been challenging to maintain the critical cultural roots of cultural safety (Ramsden, 2000, 2002). As Ramsden (2000) explained in the New Zealand context,

[t]he name remained a source of confusion to many. The popular understanding of culture as ethnicity only led to simplistic notions of cultural checklists avoiding the complex power relationships which the safety factor was intended to address’ (p. 7).

Without the opportunity to explore these issues in more depth, the unintentional risk is in fueling further misinterpretations. These opportunities must be built into mental health and addictions programming if the concept of cultural safety is to be used to its full potential (Browne et al., 2009).

Given the challenges encountered in relation to the use of cultural safety in New Zealand over the past two decades (Ramsden, 2002; Wepa, 2005), it will not be surprising if we are met with similar challenges in the Canadian mental health and addictions context. Nonetheless, cultural safety will continue to hold value in the field of mental health and addictions when used to emphasize critical self-reflection; critique of structures, discourses, power relations, and assumptions; and because of its attachment to a social justice agenda. Continued work will be required to better understand how cultural safety can be used to transform the highly politicized and complex terrain of mental health and addictions services while addressing social justice issues of relevance to Aboriginal people and communities.

We conclude this report by featuring Ermine’s (2007) call for critical self-reflection in relation to Aboriginal-state relations – here a prompt for critical reflection in the area of mental health and addictions services:

Currently, the situation, and very often the plight of Indigenous peoples, should act as a mirror to mainstream Canada. The conditions that Indigenous peoples find themselves in are a reflection of the governance and legal structures imposed by the dominant society. Indeed, what the mirror can teach is that it is not really about the situation of Indigenous peoples in this country, but it is about the character and honour of a nation to have created such conditions of inequity (p. 200).

Appendices

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List of Acronyms

Acronyms which appear more than once in the preceding report are included in the list below.

AFMC – Association of Faculties of Medicine of Canada
ANAC – Aboriginal Nurses Association of Canada
AFN – Assembly of First Nations
CIHI – Canadian Institute for Health Information
IPAC – Indigenous Physicians Association of Canada
MDSC – Mood Disorders Society of Canada
MWAC – First Nations & Inuit Mental Wellness Advisory Committee
NAHO – National Aboriginal Health Organization
NMHAC – Native Mental Health Association of Canada
NWAC – Native Women’s Association of Canada
RCAP – Royal Commission on Aboriginal Peoples

Building Bridges 2 – A Pathway to Cultural Safety, Relational Practice and Social Inclusion

Table Of Contents

Schedule A

Supporting the Mental Wellness of First Nations, Inuit and Métis Peoples in Canada: Cultural Safety
A Research Discussion Paper

Section 1.0: Introduction

1.1 Background

1.2 Key Definitions

Mental wellness is defined as self-esteem and personal dignity flowing from the presence of harmonious physical, emotional, mental, spiritual wellness and cultural identity (Inuit Specific Mental Wellness Framework, 2001, as cited in MWAC, 2007, p. 40).

1.3 Cultural Safety and Cultural Competence: A Critical Cultural Perspective

located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes. It is not therefore reduced to an easily identifiable set of characteristics, nor is it a politically neutral concept (p. 63).

Section 2.0: Historical and Present Context: The Need for Cultural Safety

2.0 Introduction

2.1 Impact of Colonization on Mental Health and Addictions for Individuals, Families and Communities

2.2 Evolution of Health Services and Consequences for Aboriginal Health

2.3 What works well

Section 3.0: What Cultural Safety Brings to Mental Health and Addictions Services

3.0 Introduction

3.1 Prompting Critical Reflection on How the Dominant System of Health Care Affects Aboriginal Peoples

3.2 Creating Ethical Spaces of Engagement in Mental Health and Addictions Care

Section 4.0: Recommendations and Conclusions

4.1 Engaging cultural safety as a concept for working toward social justice in Mental Health and Addictions Care

[t]he name remained a source of confusion to many. The popular understanding of culture as ethnicity only led to simplistic notions of cultural checklists avoiding the complex power relationships which the safety factor was intended to address’ (p. 7).

Appendices

References

List of Acronyms

Cart

Building Bridges 2 – A Pathway to Cultural Safety, Relational Practice and Social Inclusion

Table Of Contents

Schedule A

Supporting the Mental Wellness of First Nations, Inuit and Métis Peoples in Canada: Cultural SafetyA Research Discussion Paper

Section 1.0: Introduction

Mental wellness is defined as self-esteem and personal dignity flowing from the presence of harmonious physical, emotional, mental, spiritual wellness and cultural identity (Inuit Specific Mental Wellness Framework, 2001, as cited in MWAC, 2007, p. 40).

located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes. It is not therefore reduced to an easily identifiable set of characteristics, nor is it a politically neutral concept (p. 63).

Section 2.0: Historical and Present Context: The Need for Cultural Safety

Section 3.0: What Cultural Safety Brings to Mental Health and Addictions Services

Section 4.0: Recommendations and Conclusions

[t]he name remained a source of confusion to many. The popular understanding of culture as ethnicity only led to simplistic notions of cultural checklists avoiding the complex power relationships which the safety factor was intended to address’ (p. 7).

Appendices

Cart

Supporting the Mental Wellness of First Nations, Inuit and Métis Peoples in Canada: Cultural Safety
A Research Discussion Paper