The authors, Smye et al, see a particular relevance to engaging the concept of cultural safety in support of the mental health and wellbeing of Aboriginal peoples in Canada 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.

They show how the term culture can be used (or misused) to explain away discrimination and inequities, and provide a definition of culture which is more inclusive and consistent with the concepts of cultural safety and relational practice, as shown below.

Increasingly, ‘culture’ is used in health care (and more widely) to explain difference in ways that overlook structural inequities and imply inferiority. “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”. 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. More insidiously, conflating culture with racialized characteristics, masks discrimination and inequity with more neutral terminology and the perceived “inferiority” of the Other becomes normalized and naturalized.

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”.

Culture is dynamic, it is a relational concept.

As a concept, cultural safety focuses on understanding how structural inequities, systems of health care and dominant health practices affect the health status of minority and Indigenous people, and how a critical examination of these can shift attitudes and result in the development of systems and practices of health care that are more supportive of marginalized groups and their specific needs.

The authors elaborate further on this by saying:

The notion of culture in cultural safety is used to address the relational aspect 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 their everyday lives?’; and/or ‘Will the individual and/or family qualify for housing supports given their Aboriginal status?’.

In Canada, there has been a growing realization that mainstream health services, including mental health services and programs, are not effective or accessible for many Aboriginal people. To address this, the authors note that it is important to understand the historical and structural contexts within which these services for Aboriginal people have evolved and to consider culture in ways that directly address issues of racism and inequity. They review the effects of colonization, oppression, discrimination and institutional racism on the mental health and well-being of Aboriginal people; and explain how these forces have shaped and continue to shape the ways that Aboriginal people access and experience health care services, and to influence their health outcomes. For instance, the implementation of assimilationist policies under the Indian Act caused the social, political and cultural break-down of many Aboriginal communities and created long-term trauma. These policies included but were not limited to: taking traditional lands, outlawing ceremonial and traditional practices, and coercing Aboriginal families into placing their children in residential schools where the process of assimilation into the dominant society could be undertaken with impunity. The residential school experience has been particularly devastating to the culture and wellbeing of Aboriginal people in Canada, involving as it did the forced removal of children from their families and communities, harsh punishment for any expression of their culture including speaking their languages and in many cases, rampant abuse and neglect. According to the authors:

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, a detachment to others, their families and cultural communities. In fact…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”.

Within the context of the trauma suffered by Aboriginal people in Canada as a consequence of these colonialist and racist policies, Dr. Smye et al review what practices work well for promoting mental wellness and healing. Best practices include reconnection with culture and with traditional ways of healing and healing concepts; community-based initiatives and a balanced approach to mental health including treatment, prevention and health promotion strategies; and healing projects that address the historical and inter-generational trauma resulting from the residential school experience.

The authors then discuss what the concept of cultural safety could bring to mental health and addictions services for Aboriginal people in Canada, pointing out that:

…cultural safety cannot be easily defined and “neatly packaged” as a concrete set of standards for practice. 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. For example, grasping the issues that we conceptualize as core to cultural safety, such as 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.

Despite these potential challenges, the authors suggest that cultural safety as a concept can add significant value to mental health and addictions services for Aboriginal peoples by:

prompting critical reflection on how the dominant system of health care affects aboriginal peoples, on the values and ideologies that influence mental health and addictions services – and simultaneously reflecting on whether there are new possibilities for conceptualizing and delivery mental health and addictions care.

Cultural safety can be integrated into both practice and policymaking, and critical reflection can occur on a number of levels. As examples:

1. Practitioners can hold up for scrutiny their own and others’ knowledge claims, taken-for-granted assumptions and practices and seek ways to engage in dialogue about these in health care delivery settings.
2. Cultural safety can…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. For example, cultural safety can be used in support of legitimate claims for damage from past inequities and abuses, such as the cultural and individual damage that resulted from the residential school experience.
3. Cultural safety can be used to question what premises and intentions are at the heart of the ongoing calls for “cultural sensitivity” training and programming in mental health and addictions, and to inform education and training curricula.
   
4. Ethical standards can be informed by the concept of cultural safety and these have the potential to, in turn, inform the development of prevention, promotion, and treatment programming in the area of mental health and addictions involving Aboriginal people. 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.
5. At the organizational level, cultural safety is connected to a …commitment to recruit Aboriginal and non-Aboriginal staff who are committed to, and can enact, a particular philosophical approach to service delivery.
6. 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, and to ask questions about the moral rightness of policy decisions. It can inform the development of a framework to assess 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.