Building Bridges 2 – A Pathway to Cultural Safety, Relational Practice and Social Inclusion
Schedule C
Western Canada Focus Groups
Holding Hope in Our Hearts: Relational Practice and Ethical Engagement in
Mental Health and Addictions
Background Paper
In this Mental Health Commission of Canada Project conceived by the First Nations, Inuit and Métis Advisory Committee (FNIM AC), researchers were led by the voices of those with most direct experience and knowledge of mental health and addictions services. We gratefully acknowledge service providers, service recipients, caregivers, community mental health advocates and family members who participated in the Western focus groups, and the people such as Doris Greyeyes (Saskatoon), Lori Idlout (Iqaluit), Arlene Hache (Yellowknife), and Gaye Hanson (Whitehorse) who assisted in bringing these participants together.
Building Bridges is the creation of the Native Mental Health Association of Canada (NMHAC) and the Mood Disorders Society of Canada (MDSC). Building Bridges 2 partnered with the FNIM AC, and together they sponsored production of a DVD, commissioned two research papers, conducted a successful symposium, organized and managed the focus groups and produced this background paper. We are pleased to acknowledge contributions from members of these two non-profit associations and the First Nations & Inuit Branch (FNIHB) of Health Canada: Dr. Brenda Restoule & Dr. Ed Connors (NMHAC); Phil Upshall & Richard Chenier (MDSC); Kathy Langlois and Dr. Patricia Wiebe (FNIHB). We also express our appreciation to:
- Dr. Vicki Smye (UBC Nursing), and Dr. Barbara Everett, for their research work;
- Orca Productions for the filming and production of the DVD;
- People who shared lived life experience in the DVD;
- Richard Chenier and Bev Bourget for organizing and facilitating the Eastern Canada Focus Groups;
- Members of the FNIM AC;
- Sandy Murphy for her assistance in editing and formatting.
It has been a pleasure for us to work in tandem with Dr. Caroline Tait, Lead for the Ethical Programming Project, a sister project to Cultural Safety, and to have the on-going support from the MHCC staff, especially Gail MacKean, Jayne Barker, and Howard Chodos.
All My Relations
Bill Mussell, Margaret Terry Adler, Gaye Hanson, Dr. Jennifer White and Dr. Victoria Smye, members of the Cultural Safety Working Group, FNIM AC.
Background
As part of their ‘Building Bridges’ initiative, the Mood Disorders Society of Canada (MDSC) and the Native Mental Health Association of Canada (NMHAC) collaborated with the First Nations, Inuit and Métis Advisory Committee (FNIM AC) to the Mental Health Commission of Canada (MHCC) in a joint research project to understand best and promising practices that constitute cultural safety and relational practice in the Canadian context. In 2009, they commissioned a total of forty-one focus groups in Western and Eastern Canada, a national symposium in Ottawa in 2010, and two research papers, one on social inclusion, the other on cultural safety. The purpose of this background paper is to provide an overview of findings from the Western focus group consultations. A report incorporating further analysis will be completed by April 2011.
Research Question
“What will improve practice in mental health and addiction services for all Canadians?” is the central question in this project. Focus group participants included practitioners and recipients of services, with approximately two-thirds aboriginal, one-third non-aboriginal, the majority working in aboriginal-led organizations serving indigenous people. The focus on mainly aboriginal agencies, their staff and clients, was intentional, as aboriginal voices have seldom been privileged.
Findings
Six overlapping categories were developed to capture the emerging themes and organize research findings: direct care; interpersonal relations; professional development; ways of knowing; organizational context; and policy.
- Direct care refers to the qualities of the care provider/care recipient relationship.
- As viewed by participants, the relationship needs to be accessible, inclusive of the disabled, respectful and responsive to the uniqueness of each individual, strengths focused, flexible, trauma informed, acknowledging of grief, and making use of human connection in healing.
- Interpersonal relations refers to the range of relational networks and formal and informal supports in which both the care provider and recipient are embedded, including relationships with families, community members, colleagues, peers, mentors, supervisors, other service providers and agencies. Participants emphasized the importance of reciprocity and dialogue, support for self-care, self-awareness and conscious growth, and the necessity for circles of support for both care provider and care recipient.
- Professional development refers to the informal, non-formal, and formal knowledge and skill development received by professionals in the course of their training to become a mental health practitioner, as well as the multiple life experiences and cultural practices that care providers draw upon in their work. On this topic, participants shared insights about informal, non-formal and formal education/training, mentoring, lived experience, balance and harmony, and wisdom teachings.
- Ways of knowing refers to the approaches taken to understand, document and make sense of the social world. “All my relations”, cultural continuity, the power of story, and tensions between Western and Indigenous ways are themes that emerged in the focus groups.
- Organizational context refers to workplace norms, policies, resources, agency mandates and professional routines. Participants spoke about organizational norms, centralization vs. decentralization, integration of services, family and community context, and healthy effective organizations.
- Policy challenges refer to government legislation, policies, and funding. Significant challenges identified in the focus groups include the tension between individual and collective rights, between biomedical and complementary approaches, and concerns about the capacity for response to ethical dilemmas.
Domains for Consideration
Five topical areas emerged from the findings as well as the process through which the project evolved; they are ‘group process and leadership’, ‘guiding principles’, ‘practices’, working metaphors, and liberating concepts as building blocks as summarized below.
- Group process and leadership – the research model chosen was based on inclusion, participatory methods and indigenous ways of sharing knowledge both with the focus groups and within the working group. Dialogue with the data and between researchers led to a new way of understanding mental health and addictions as a human experience.
- Principles – eighteen principles are identified in the report: honouring humanity and human experience; centrality of connectedness and relationships; valuing and learning from diversity; “do no further harm”; patience; deep listening; radical acceptance; reconnection; respect; collective healing; community of practice; strengths based; relational attunement; honouring boundaries; recovery model; nature as healer; culture as healer; prayers and ceremony.
- Practices – eight associated practices emerged as key findings: fundamentals first; becoming and honouring human process; silence, nature and “being with” as therapy; culture as therapy; shared living; manage fear; no experts’ zone; programming with options, multi-year funding and community-driven.
- Metaphors – three metaphors arise from the findings: spiral as connected completed circles, two-way street and walking together.
- Liberating Concepts – twelve key ideas derive from the findings: many choices and freedom to choose; return to the large human tribe; all life matters; humanized and humanizing relationships; knowing self, knowing other in context; know what you stand for and change self; circles within circles; ripple effect; speak the truth in love to people; intentional disruption is good; healing and recovery as learning and growth; intuition, wholeness and change.
Recommendations
A. Next steps:
- Endorse the Eastern Focus Group Report
- Link with Ethics Working Group
- Disseminate East and West reports together with a joint summary paper
- Support development of “Building Bridges 3” through: a) dialogue forum, b) case studies of promising practices, c) mining of RCAP and AHF work to expand foundational learning (d) Website creation and (e) international collaboration.
B. System change: knowledge development through group dynamics paper, presentations and publications
C. Education and Training: curriculum development and training
D. Policy development: develop relational and ethical engagement policy lens for policy analysis
E. Program/Services delivery: joint development and sharing of resources for renewal of system.
As part of their Building Bridges initiative, the Mood Disorders Society of Canada (MDSC) and the Native Mental Health Association of Canada (NMHAC) collaborated with the First Nations Inuit and Métis Advisory Committee (FNIM AC) to the Mental Health Commission of Canada (MHCC) in a joint research project to understand best and promising practices that constitute cultural safety and relational practice in the Canadian context. In 2009, they commissioned a total of 41 focus groups in Western and Eastern Canada, a national symposium in Ottawa in 2010, and two research papers, one on social inclusion, the other on cultural safety.
The question central to the project was: “What will improve practice in mental health and addiction services for all Canadians?” To find answers to this question we conducted focus groups in Western Canada involving practitioners and recipients of services, approximately two thirds of them aboriginal, one third non-aboriginal, the majority working in aboriginal-led organizations serving indigenous people. The focus on mainly aboriginal agencies, their staff and clients, was deliberate. It is generally accepted knowledge that historically, health care in Canada has been dominated by the illness and health belief systems of the dominant culture and has disregarded those of indigenous people (Smye and Brown, 2002). The outcomes for Indigenous health have been poor. By listening to people rarely consulted, situated in contexts seldom researched, the authors attempted to document some of the interests, values, beliefs, and principles that may hold promise for improving the health and well-being of indigenous and non-indigenous people, as a contribution to transforming the mental health system in ways beneficial to all Canadians.
This background paper describes how the authors conducted the Western focus groups and the analysis of the transcripts. It presents our findings about cultural safety, relational practice and ethical engagement and invites discussion regarding the implications and opportunities for a transformed mental health system in Canada. Further analysis is ongoing and will be incorporated in a final report to be published and disseminated by April 2011.
The Western focus groups were held in Saskatoon, Winnipeg, Iqaluit, Yellowknife, and Whitehorse in October and November 2009. A total of 147 people participated. Of these, 97identified themselves as indigenous (22 Inuit and 75 First Nations or Métis). Those in provider roles numbered 108 and those with lived experience 39. A significant number of providers (25) reported having gone through their own healing journey, with or without formal assistance, to evolve into care providers themselves. Participants working for or receiving assistance from indigenous based organizations constituted 56% of the total, non-governmental organizations approximately 29% and governmental 15%. A detailed demographic of participants can be found in Appendix A and Appendix B. The Executive Summary of the Eastern focus groups can be found in Appendix C.
The focus group facilitators’ longstanding relationships with key stakeholders in the communities enabled them to draw upon existing community networks to form the sample population of convenience. Stakeholders’ investment of time and energy was motivated by their interest in the purpose of the project and its outcomes.
Discussions were grounded in an overview of the project context. Focus group facilitators explained that the initiative is intended to contribute to the joint efforts of the FNIM Advisory Committee within the Mental Health Commission of Canada, the NMHAC, and the MDSC to further the understanding of culturally safe practice in mental health and addictions.
Through a process of circle dialogue and story telling, participants reflected on their experiences with mental health and addictions services, what was working, what was not working, and what could be improved. Participant concerns led the emergent discussion and spoke to the unique characteristics of group members with respect to their geographical location, the types of services and systems they dealt with (governmental, non-governmental, aboriginal or consumer-led), to their challenges, and ways of addressing these. Sessions were audio recorded and transcribed. Transcription totalled 583 pages of rich information, thoughts and stories from participants.
The process of making meaning of this wealth of information was shared by the five members of the FNIM AC cultural safety working group (that includes the two focus group facilitators). Transcripts were closely read multiple times and emerging themes and potential framing metaphors were identified. The first meeting of the working group resulted in a shared vision of the intent and design of the focus group background paper. Given the complexities of current mental health and addictions challenges, and the multiplicities within society, the group saw the value of the paper to inhere in its ability to open a dialogic space between as many people as possible; to invite them to engage, reflect and work together to arrive at new understandings from which fresh solutions may emerge. To achieve this, the approach taken in analyzing the transcripts was an emergent, collaborative one, in which meanings were negotiated in group discussion, patterns were sought, and complexities maintained. Each of the five working group members read a set of transcripts from one of the five cities visited. Members then met to share their perspectives and discuss the iterative interplay between the lived experience of focus group participants, the published literature, and the policies and practices that constitute the context, in order to highlight the layers of complexity of current reality. The group continued to meet, either in person or through teleconference, to deepen their understanding and analysis.
While focus group participants testified to the challenges in the current mental health system, they spoke more extensively of what works, how they conceptualize culturally safe practice, and what they want. Following multiple readings of the transcripts, and consistent with the literature (Smye & Browne, 2002), it became apparent that cultural safety is a process that is multiply determined, contextually embedded, and relationally mediated. For the purposes here, cultural safety is described as a relational concept marked by ethical engagement. Cultural safety is action-oriented in that culturally safe practice addresses power dynamics in health care, challenges social and structural inequality and is characterized by interpersonal relationships that take into account the social, political, historical and cultural factors that influence peoples’ lives, understanding that health and health care are shaped by these factors. Cultural safety is not something that can be conferred or imposed. It is the outcome of relationships characterized by mutual respect and equality. Six interrelated categories were identified to capture the themes emerging from the focus group analysis:
- direct care
- interpersonal relations
- professional development
- ways of knowing
- organizational context
- policy
Figure 1 graphically provides one example of how the larger context that includes socio-political and historical factors works with the natural world, land and physical environment (including human constructed things and systems) to influence our relational and ethical engagements. The six aspects that will be used to organize findings are captured in the over lapping segments– these are interrelated and contribute to the forces that both enable and constrain relational practice and ethical engagement which rest in the centre of the model. 1 Some of these categories have been drawn from Dr. Jennifer White (2007) Knowing doing and being: A praxis-oriented approach to child and youth care.
1 Some of these categories have been drawn from Dr. Jennifer White (2007) Knowing doing and being: A praxis-oriented approach to child and youth care.
Figure 1
The findings have been organized using the six aspects depicted in the model above – direct care; interpersonal relations; professional development; ways of knowing; organizational context and policy. The categories are interrelated; many of the stories and findings arising from the stories could have been captured in several different ways in more than one category.
Direct care in the context of this project refers to the qualities of the care provider/care recipient relationship. Focus group participants expressed that direct care needs to be: accessible (physically, emotionally, mentally, and spiritually), inclusive of the disabled, respectful of and responsive to the uniqueness of each individual, strengths-focused, flexible, trauma-informed, acknowledging of grief, and making use of human connection in healing. They emphasized the interconnectedness of the physical, emotional, mental and spiritual needs and the necessity of addressing these in their wholeness, since in the person of the recipient of care they are always interrelated, not fragmented.
Access
Direct care should be physically accessible in terms of its location, eligibility criteria, environment, and provision of handicapped access; emotionally accessible through assurance of confidentiality and welcoming staff who encourage and support movement beyond fear, stigma and discrimination; mentally by providing materials in different languages (appropriate to the geographic area), through reading and literacy levels that match the readiness of potential clients; and spiritually, validating of personhood, soul, and culture.
“A person can walk in here and say I have this problem, could I see someone, and that person would be accepted and told we would call them back or be seen face to face right away if that was possible. Someone always goes to talk to them right then.”
– Service Provider [SP] Whitehorse
An accessible service is one that is well located and designed, properly staffed by compassionate and appropriately skilled people who are non-judgmental, have strengths-based respectful approaches, and invest in building social supports. Staff is well networked with complementary services and agencies (one door, many resources) with the capacity to respond to basic needs in practical ways including provisions for food, clothing, shelter, safety.
“You can talk all you want, but after the talk is done and the session is over, they’re back on the street… so you know housing is a necessity, a major issue…and if they need to have psychological help, get them that help, and if they need detoxification, then get them into a treatment program, and if they need further education, you know, go for it, but if they’re willing to take on a job, well then, get them one…”
– Service Recipient [SR], Yellowknife
The desired service philosophy is decolonizing and humanizing, and addresses root causes, rather than offering only a superficial “fix”.
“We specialize in core issue therapy, rather than deal with things piece meal. We have a program of healing that …shows you where all this is coming from and gives you the tools for living today.”
– SP, Saskatoon
Inclusiveness and disability
Inclusiveness is an important feature of an accessible service. Inclusiveness means designing and delivering services that are specific for individuals with special gifts, FASD, brain injury, and other abilities and disabilities in order to adequately meet their unique needs. The price of inappropriate access for people with disabilities is underscored by the following comment by a participant in Yellowknife.
“Because of my disability background, I recognize that many of the people I’ve worked with in the correctional custody or on the streets are horribly disabled. These are people who, if they had escaped brain damage before they were born from whatever toxic substances they were exposed to, continue to sustain head injury from falls, blows to the head, substance abuse or addictions issues. We take those people and put them into correctional custody where even the guards say ‘they don’t belong here-they’re mental’. And correctional guards are not trained to work with people with disabilities; they are trained in security work. We have got mentally ill people who have been using substances to deal with their disabilities in expensive government-run facilities called jails. It is not an effective way of dealing with homeless, addicted, mentally ill people.”
– SP, Yellowknife
Respectful and responsive
In the direct care process, each individual needs to be met where they are and as they are ready to “find a place and make a space.” The relationship must be reciprocal, a collaborative partnership, with the needs and readiness of the care recipient guiding the unfolding agenda. A menu of choices needs to be offered and options provided with unconditional acceptance as a vital prerequisite.
Strengths – focused
Helpers need to believe in the ability of people to change while honouring their diversity and finding strengths-based approaches that work for them. A strengths-based approach is more positive and effective than a deficiency focus because it focuses on what the recipient of care brings, including their culture. It looks truthfully at problems while patiently building on the capacity and potential of the individual for positive change.
“What we do works because we are building on strengths. We’re building on a positive foundation, and that makes all the difference in the world.”
– SP, Saskatoon
Flexible
Non-Government Organizations (NGOs) often are able to provide more individual, group and community-based creative responses that are also cost effective. Government agencies have more constraints around which they must manage in order to innovate and respond to community needs and challenges. “What we do have as NGO’s is a kind of freedom of thought; we don’t have the government culture coming down on us, having to tow the party line.” (SP, Whitehorse) Flexibility in shaping a care plan according to individual needs and circumstances is a major determinant of successful outcomes. Underlying this is the principle that “the answers are within us”; the expert is the person who is living the life.
“I don’t know what these individuals have been through, so the client centered approach allows me to let them heal at their own rate with the means they know best rather than me imposing as an expert and telling them to “do this”.
– SP, Whitehorse
“I think another reason our constituents come to us is because we give darn good, comprehensive service in whatever will meet the constituents’ needs, so it’s informed by constituents’ choice, constituents’ strength.”
– SP, Winnipeg
Trauma-informed
Any effective service needs to incorporate a knowledgeable and skillful approach to individual and collective trauma and racism while at the same time, recognizing and believing in peoples’ capacity to “embrace life” in their own unique ways. While trauma is a reality in the lives of many Canadians, for aboriginal people individual and intergenerational trauma is a consequence of colonial processes and practices. Historically and currently, Aboriginal people experience trauma related to the undermining of safe family and community connections, loss of land, culture and language. Systemic racism, covert and overt, erodes a positive sense of personal and cultural identity and wellbeing.
“With our FN people, there are all those experiences of abuse added to the effects of colonization on our people as a whole.”
– SP, Saskatoon
Grief as universal
Unacknowledged losses are experienced by many Canadians. Indigenous people have a backlog of grief connected to colonization and high rates of loss of all kinds that creates a somewhat unique context. To be effective, care providers need to understand how the burden of unresolved personal and historical losses carried by many recipients of care may shape present behaviour.
“They suffered, and because their children suffered, their grandchildren suffered. Now I am saying each of these three generations needs counseling.”
– Community Member [CM], Yellowknife
Use human connection
One of the most important things aboriginal people have been deprived of has been human connection. To enhance and augment the value of individual therapy, many care providers use small groups and other collectives for re-creation through play, social and practical activities that support relearning the healing nature of “fun” while building positive relationships and developing life skills. Some services are activity based, rather than just “talk therapy”; for example, hunting on the land, going fishing, making a meal, crafting an implement or camping.
“We do cultural skills training…cabinet making, small tools, and repairing snowmobile engines.”
– SP, Iqaluit
Interpersonal relations refers to the range of relational networks and formal and informal supports in which both the care provider and recipient of care are embedded, including relationships with families, community members, colleagues, peers, mentors, supervisors, other service providers and agencies. Focus group participants emphasized the importance of reciprocity and dialogue, support for self-care, self-awareness, conscious growth, spirituality and the necessity for circles of support for both care provider and recipient of care.
Reciprocity and dialogue
The care provider’s work is characterized by a quality of reciprocity and dialogue based on a perception of the recipient of care as equal in value to themselves, as being a teacher as well as a learner in the relationship, and as capable of becoming proactive in building and maintaining their wellbeing.
“I learn something new every day from clients, who have a lot to teach us.”
– SP Saskatoon
Self-care
Self-care is a priority for both care provider and the recipient of care. In order to help others, practitioners must continually deepen the way they honour and nurture themselves and role model a commitment to self-awareness, spiritual development and conscious growth that supports their capacity to “show up” relationally. An outcome of the commitment to nourish ones’ developing self awareness and personal capacity is a growing personal presence, “walking your talk” and/or “finding of voice” for both provider and recipient of care.
“…if you are going to get into this field, in order to be of help to anyone you need to be coming from a place of strength; that means I need to take care of myself first. You need to deal with your own stuff first, so you don’t put your stuff on to anyone else.”
– SP, Whitehorse
“We have a ‘heal the healer’ first situation because we have students dealing with abusive relationships, PTSD, substance abuse. We had to intensely work on getting the potential healer to be healthy first so…there was a lot of work, academic and counseling at the College. We hired a counselor specifically to work with the mental health students because of the fact that we have such difficult issues to face. So it is a continual work; it is not something that is going to happen in two years.”
– SP, Iqaluit
When renewal and healing is as much part of the human journey for care providers as recipients of care, it contributes to a loving and intentional presence that is one of the most powerful gifts one can bring to the other. Healing must be multi-faceted, realistic and a life-long process. We each have our own ways to heal, grow and develop our gifts and full potential. Practitioners who “walk the talk” are most effective in guiding people living with the challenges of mental health issues through their own unique process.
“Until you have something traumatic happen to you, it’s really hard to open yourself to understand what other people are going through. I had some traumatic things happen, so it just created something inside of me that I wanted to help. I felt that my experiences made me a more caring, open, patient, understanding person, and I find this job requires so much of that. And I think that I am good because I am not very judging. I tend to just see people as people. You are not this illness or that illness; you are just a human being. I try to be a good listener and try not to say, you need to do this or you need to do that, and just let them talk and solve their own problems by kind of guiding them through. Because I don’t have all the answers, and I believe that they do.”
– SP, Yellowknife
Circles of support
By definition, circles are inclusive. No matter where one is on the continuum of wellness, he/she deserves a place in our world and has gifts to contribute to others. Care providers see one of their most important roles as “bringing people into the circle”, building social connections and peer support through healing and recreational approaches as well as group therapy.
“We do our Healthy Living Program; they make soup, socialize, and work in activities. We always work in new ideas with input from the people that come. Outreach does a lot of excursions in the summer…like going to have picnics and barbeques and to just get folks out of town to see the wilderness and nature.”
– SP, Whitehorse
Care providers recognize that there is a special quality in learning from peers and group dynamics that allows them to work through family and group related traumas and find new versions of “family” and “community” with the recipient of care. Importantly, providers see that this applies to themselves as much as to recipients of care. They affirm the necessity for supportive environments that promote their own personal and professional growth and development, without which there is stagnation and burnout. Such supports sustain relational practice, which thrives in a nurturing collegial community.
“It is a difficult job to do on your own because clients are very complex. I do a lot of networking. Networking is essential to me.”
– SP, Saskatoon
Professional development refers to the informal, non-formal and formal knowledge and skill development received by professionals in the course of their training to become a mental health practitioner, as well as the multiple life experiences and cultural practices that care providers draw upon in their practice. Participants contributed the following about professional development; insights about informal, non-formal and formal education/ training, mentoring, lived experience, balance and harmony, and wisdom teachings.
Education/Training
In every culture, education begins in our families and communities, where many of our most important values, attitudes and beliefs are first nurtured. The institutions of the formal education system are more successful when they build on the foundations laid in the early years. For many aboriginal learners, there is a significant “disconnect” between the cultural orientation of home and that of school, making it very challenging for them to reconcile and apply school learning to the realities of their personal and professional lives.
“When I took my social work training it was all westernized, there was nothing aboriginal about it. Later training was all changed and I was able to really incorporate a lot of what I had learnt there, because it was good, focused on Northern remote aboriginal communities, and because I had already learned a lot about my own culture and my own identity.”
– SP Yellowknife
For non-aboriginal service providers in mental health and addictions to be well-prepared to serve aboriginal people in culturally meaningful ways, their professional training must be congruent with indigenous understandings of health, illness, healing and history.
“We have people coming into social work who have very good intentions, they want to be helpers. They are learning that the impact of colonization is still going on, and instead of an approach to healing that ‘medicalizes’, they learn about social suffering and the power of acknowledging where people are and that their responses to atrocious things that have happened are pretty normal.”
– SP, Yellowknife
When formal education and training incorporates informal and non-formal strategies that allow people to experience relational practice marked by ethical engagement, this can support and foster human development, knowledge and skills acquisition. Methods for incorporating meaningful teaching of relational practice and ethical engagement remain under construction. The following strategies emerging in current mental health and addictions practice provide promising strategic directions.
Mentoring
When done in a good way, the development of mentoring relationships across generations, across disciplines, across agencies and across cultural divides can promote very significant learning and support new capacity development related to relational practice and ethical engagement. Mentoring and role modelling are powerful ways of teaching and learning.
“People with more advanced training need to go to the smaller communities more often to help support and train people working in the community.” (SP, Whitehorse) “The nurses that are in a consulting role are using the resources in the communities to consult, to teach, to assist, all of that, so you are building up your communities.”
– SP, Whitehorse
“Our team members have gone out to several of the communities and done micro-skills and counseling education, so it builds capacity for them. We respond; we don’t impose.”
– SP, Whitehorse
The caution here is that mentoring and role modeling can also be the methods through which organizational toxicity is transmitted.
Valuing own woundedness and healing through lived experience
We are all wounded and must honour our own woundedness. With our woundedness and our commitment to healing comes an obligation to be fully engaged in our own lived experience. That lived experience as it unfolds moment by moment is the crucible of relationship that we bring to each engagement. This dynamic either affects our relational space within our awareness or out of our awareness – the effect is there either way. Deeply reflective practice involves seeing life as a spiritual journey and opens the helper to be helped. To act out of unawareness increases the potential to harm another. As we gain further awareness and proficiency in our own process, we can help others. Many care providers and consumer advocates testified that their on-going learning from self-reflection based on lived experience serves as their most valuable resource in working with others.
“If someone hasn’t worked on their own stuff, they are of no help at all.”
– SP, Saskatoon
“The significant difference between our organization and other organizations is people on our board and people that work there have had problems. We have no difficulty saying that we needed help and we had problems, and we helped each other.”
– SP, Yellowknife
Balance and harmony
“Bringing people into the circle” means providing a range of teaching and learning methods and content options to people at the individual, family, group and community levels. Rural and remote communities need relevant and accessible options and resources for building internal capacity. Needs, strengths and resources must be balanced to support equitable access to professional development opportunities that further support equity in health status for all Canadians whatever their culture, geographical location, or socioeconomic status.
“You need the diversity; you need the people on the ground who can be the generalists, who can do the care, provide some problem-solving and support, and you need the people with the training who can guide the people on the ground or assist when you have people who are suicidal.”
– SP, Whitehorse
Wisdom teachings
Wisdom can be gained through experience and through spending time with people whose knowledge is physically, mentally, emotionally and spiritually integrated. To find ways of accessing wisdom from a spiritual tradition or traditions that are in alignment with one’s path and making time and space to learn is one of the best investments possible in human growth and development. When practitioners have opportunities for interpersonal learning of wise teachings from multiple perspectives without the privileging of one over others, they can build on the strengths of all.
“We don’t need to teach the elders, they are already taught, and they are already professors and experts in their domain. It’s the people that we are training right now in schools that we have to help them to think about the strengths, and alternative forms of healing for our people.”
– SP, Yellowknife
All my relations
This phrase embodies the value and importance of relationships to generations that have “gone before” (ancestors), the generations that will come after (yet unborn), land (a place that remembers you), community, cultural and traditional paths, language and all elements of the natural world. All of these are of central importance to most aboriginal care providers and recipients of care, and become significant to non-aboriginal care providers working with aboriginal people.
Cultural continuity
“I have been a survivor of suicide, I have been a survivor of mental health issues, and the reason I was able to get back on my path was the culture. Without the cultural teachings and without elders’ help I do not know where I would be today.”
– SP, Winnipeg
The Power of story, re-storying and restoration
The power of stories was a strong thread in the focus groups. Indigenous people and client groups are often the objects of stereotyping and social exclusion or victims of a single story that simplifies and essentializes the diversity of human realities and in that process, dismisses much that is true about the group about which the story is being told. Part of therapy and healing is to understand how our stories are the outcome of our lives and contribute to perpetuating patterns in our lives. We do not always tell ourselves a truthful or complete story. The potential for restoration through re-storying our lives is powerful. The re-storying must take place on both personal and societal levels, so both the care recipient, care provider, and the socio-political contexts in which they live are freed from the shackles of the dehumanizing single story.
“Every person has his or her own story. You can’t label because each person is unique.”
– SP, Saskatoon
“One night I was sitting with three co-workers and started talking about treaties and colonization. I was thanked by one co-worker who said she learned more from me in 15 minutes than from all the hours of equity training, aboriginal awareness. So, if that is going to be my role on the floor, I will educate them, I will try to ignore their ignorance and their discrimination to hopefully help them see a little more from my perspective, not the narrow view they have.”
– SP, Saskatoon
Tensions between Western and Indigenous ways
Indigenous people with limited experience in highly complex government organizations often need assistance in developing the organizational literacy to be able to see and deal with tensions between what they may view as right and good and the organizational culture in which they find themselves. Non-indigenous members of the organization also need help to make explicit and change organizational values and practices that block effective service delivery.
“When you end up working for government, it ends up being another level of challenges because of the hours you’re constricted to, or the office. It’s just not conducive to the cultural way of helping that was the reason they wanted to be helpers, to help their community, and they end up having to use a government process that is very foreign to them.”
– CM, Iqaluit
Underlying these tensions is a fundamental difference in the ways in which mental health and mental illness are conceptualized from western and aboriginal perspectives that has implications for all aspects of a mental health system.
“The frames of reference in FNs compared with the western world in terms of what wellness means are radically different.”
– SP, Whitehorse
“Mental health is a very Eurocentric word…our government is thinking about this as an individualized personal problem inside our minds… and needs to think about these concepts differently.”
– SP, Whitehorse
“For mental health, you have to know who you are, your history and where you are going because it is the root of who you are. Mental health has to recognize the treaty relations because that is the basis of who we are within Canada and that’s what cultural safety is. It’s us running our own organizations, our partnering, but we are real partners; we are not just at the table.”
– SP, Yellowknife
Organizational context refers to workplace norms, policies, resources, agency mandates and professional routines. Focus group participants spoke about organizational norms, centralization vs. decentralization, integration of services, family and community context, and healthy effective organizations.
Organizational norms
Positive norms support good practice. In organizations, there may be tensions experienced between indigenous and non-indigenous ways of knowing being and becoming when culturally different groups work together. The indigenous imperative to be respectful and responsive to people, sometimes at the expense of policy is not always supported in organizations. Concerns about budgets and efficiency may well trump client-centered concerns. Indigenous ways of knowing are relationally led and informed. From an indigenous perspective, the needs of the recipient of care ought to guide the helping process, and policies and procedures that block or circumvent effective practice need to be identified and addressed.
“We are status blind; we serve anyone who is aboriginal, Inuit or Métis.”
– SP, Winnipeg
“The two systems (First Nations and non) are so different. One is about appointments and procedures; these did not work in the small communities.”
– SP, Whitehorse
“With the amalgamation of services, the manager role is more worried about admin and financial management (not paying overtime or sick time) than developing teamwork. There is no teamwork on our floor. Five years ago, the focus was on the best patient care. The team leader was accountable, looked after the staff so they could be well rested and provide the best patient care. The new manager came in with different values. His approach is all about the budget and time management. If he meets the budget he gets a nice bonus at the end of the year.”
– SP, Saskatoon
“Your system reflects your approach. When I was hired, my boss said here we aren’t hierarchical; we are all equal whether your work is to answer the phone and greet people or you are a clinician. We are on one page, every opinion matters, everybody is deserving of equal respect. So that whole kind of we are one, we are equal philosophy passes down to clients.”
– SP, Whitehorse
Centralization versus decentralization
Many participants noted the importance of Aboriginal self-determination. Autonomy and self-direction at the local level ensures the best fit of service to need. A balance of centralized and decentralized services needs to be achieved and maintained dynamically in order to maximize the effect of resources invested and to get the services as close to the people as possible. For example, organizations that provide services to rural and remote populations need to have the authority and capacity to design and deliver appropriate programs and services to diverse and dispersed people.
Integration or linking of services
Innovation is needed in some cases to find new ways of integrating, bringing together or linking services. Focus group participants talked about people “getting lost in the cracks” due to lack of good linkages that work for people. Many participants spoke about the need for health services to link with housing and educational and employment opportunities. As one participant noted, “like for me it’s hard to find a decent job because I’ve got no education. I can’t really get anywhere unless I try,” and for another, “it would be good to have small-income loans and low-rental places for people that need a place to stay.” (Service Recipients [SRs], Yellowknife) “Housing is a huge challenge for a lot of people, especially for women.” (SP, Saskatoon)
Partnering between agencies or individual helpers is one way to link capacity to serve.
“We try to address as many of the determinants of health as we can, so in terms of facilitating movement out of poverty, we will focus our attention on securing the educational supports…social supports…all of those linkages, where we take them and pick them up and bring them back…the transportation to do their grocery shopping or go to their medical appointments so that they can consistently attend to their health needs.”
– SP, Winnipeg
Another major challenge is to link mental health with addictions services.
“Most indigenous people that have mental health issues have addictions issues, but we have no way of accessing the mental health issues because we have no way of accessing the addictions issues. We need to provide stabilizing services to people, connect with those people, so they can then access mental health services, which we still have to develop.”
– SP, Whitehorse
Family and community context
Many participants noted the importance of the interconnectedness between the individual, family and community. They recognized that the individual needs a healthy family and community context to build and maintain their own wellbeing. The capacity to serve“community as client” through community development, capacity building and other growth oriented pathways needs to be greatly enhanced throughout the system. The continual repetitive use of individually focused interventions disrupts the integrity of family and community systems.
“The answer is the community having resources and having time. I think it is important somehow that we get out of the way to allow the community to connect with processes that are connected with elders and ancestors.”
– SP, Whitehorse
Healthy effective organizations
Just as organizations need a cycle of renewal, so does a priority need to be placed on investing in, supporting and rewarding staff growth and development – both personally and professionally. Healthy organizations that are effective need to invest in planning, implementation, harmonization and evaluation in a balanced way. Often organizations fail to fully invest in planning and evaluation or learning from clients and front line workers so as to inform and reform those processes. With the focus on implementation, the capacity to harmonize with sister agencies, volunteers, family and clients is often compromised.
Policy challenges refer to government legislation, policies, and funding. Significant challenges identified in the focus groups include the need for policy supports for sustainable funding, tension between individual and collective rights, between biomedical and complementary approaches, and concerns about the capacity for response to ethical dilemmas.
Policy supports for program funding
Program funding that truly serves people is adequate, equitably distributed, multi-year (up to five years) and begins to flow at the beginning of year one. In addition, the funding should continue uninterrupted for the full term, and if renewed, continue for the renewal period uninterrupted. The multi-year stability provides a real opportunity to demonstrate results. Monitoring, evaluation and reporting processes are strategic and should be easy to use and take a minimum amount of time and energy away from providing care. Policy and government implementation processes need to align with each other in order to maximize the ability of government and non-government community agencies to serve people. Ensuring sustainability for programs and services of proven effectiveness is also a challenge.
“Temporary funding is not the way to meet the health needs of the North.”
– SP, Whitehorse
“There’s a lot of catches to this funding money. We operate, from quarter to quarter and uncertainty is the biggest problem we face because people are fed up, rightly fed up, after many years of programs being started and they start to improve their lives and all of a sudden your funding disappears and the program’s gone. That’s the biggest problem is the sustainability. We are looking to having to close the doors on March 31st after 6 full years thanks to the Aboriginal Healing Foundation (AHF). And this year, we are $8500 short because the feds haven’t come through with the money though we signed the papers. I say live up to your commitments because if you don’t, you kill the programs.”
– SP, Iqaluit
Individual rights and collective responsibilities
The mainstream system is focused on individual rights as a primary concern that supports a policy response to individual needs. From an Indigenous perspective, collective responsibilities are seen as primary and therefore the most important response focuses on the nexus between individual and collective responsibilities. Rights, in the Indigenous view are earned through carrying out responsibilities in ways that benefit present and future generations.
“What would it look like to create a truly family friendly service that engages the family and community? We don’t think the language of diagnosis is friendly and office hours are unfriendly; there are a lot of things that are unfriendly.”
– SP, Whitehorse
Biomedical model and complementary approaches
The predominance of the biomedical model is problematic as it leaves little room for indigenous models and perspectives. It is an individualistic, curative rather than holistic approach that often conflicts with the indigenous. Participants called for building complementary approaches to create multiple ways of knowing and multiple pathways to healing and recovery.
“Our program activities are holistic; a blend of contemporary and traditional services to meet the complex needs of our urban aboriginal population in order to move them to a healthier lifestyle. We like to say we take the best out of both worlds.”
– SP, Winnipeg
Capacity for response to ethical dilemmas
Both individuals and organizations often find themselves faced with ethical dilemmas, some of which have cultural and professional dimensions. As one person said, “Who is it we go to when something happens that we cannot tell anyone about?”(Symposium Participant [S], Ottawa)Organizations need to have capacity to assist in these situations to prevent ethical blindness, burnout or moral residue as a consequence of unresolved ethical tensions that may compromise relational capacity at the service interface. Truth telling and speaking truth to power must be supported in order to build and keep trust. A recurrent example of a major ethical dilemma is the lack of program sustainability.
“Programs actually come and go so frequently that they put people into a worse situation than they were to start with.”
– SP, Iqaluit
The discussion presented is founded on a synthesis of views from participants, the analysis of the experience of the focus group facilitators, and the dialectic created in the relational space between the two. In this section, the voice of the report intentionally moves to “we” in order to speak collectively about what we have drawn as conclusions from the findings and the learning that emerged from our collective intent as a working group to “walk the talk”. The discussion blends the shared learning from the focus groups with personal and working group insights developed through dialogue with the data and each other. We chose to model inclusion, participatory methods and indigenous ways of sensing and sharing knowledge and wisdom in choosing our methods with the focus groups and within the working group. In both groups, we honored the principle of allowing the participants to direct the process as it emerged organically from one stage to the next.
The wise and responsive leadership expressed by Bill Mussell was fundamental to our collective learning. Bill, as a result of his lifelong learning, was able to design an open process for the focus groups that was both inviting and generative. Bill and Terry Adler created a space together of loving interest and inclusion that promoted significant contributions and deep sharing among participants. Focus group meetings were planned to optimize the comfort level of participants by being held “close to home” in familiar surroundings with participants who either knew one another or had much in common.
The talking circle as a method worked well, due to the way in which Bill and Terry introduced the sessions and intentionally remained open and responsive to whatever emerged from the group. The perspectives of all participants were valued and the circle was kept and held until it was finished – time was provided to allow for consensus or a natural conclusion. Bill, as the primary circle keeper, demonstrated the loving presence, non-judgmental acceptance and openness that invited people to feel safe and contribute to the level that they felt comfortable. Terry and Bill were able to help participants find ways of safely “being on the bridge” – the bridge between Aboriginal and non-Aboriginal worlds; between care providers and those receiving care; and between community and institutional ways of caring. Learning and discovery was encouraged and mediated under their leadership. Each group was seen as a microcosm of the whole and an opportunity to experiment with “walking the talk” together. The process was co-created by all the participants, and the responsibility for the outcome jointly taken.
The working group came together under the leadership of Bill and Terry to work with the information and knowledge they had collected and generated throughout the data collection phase. There was a commitment within the group to affirm and reaffirm our collective belief in a hopeful future. We were invited to hold “hope in our hearts” and to focus on strengths and possibilities while facing the current reality with unflinching courage. As we discovered, in order to hold the findings we had to be willing to let the information and growing awareness transform us. Through the emergent process, we were challenged to embody the current reality in order to hold the possibility for change in our conscious awareness – individually and collectively. The work both in person and through technology took on a loving, emergent quality and together we created the perspective needed to ensure we honoured the voices of those that took part and the many individuals with lived experience that were not able to participate. A profound valuing of the opportunity to connect with one another and make a hopeful difference became the wellspring that fed the work. The work was alive with generative cross-pollination of ideas and divergent perspectives.
Intentionality became an operative word as we visited and revisited our intentions. Meetings always began with a check-in circle to honour the fact that we bring all that we are and the connections that define us, including family and friends to the circle. In the circle, we are invited to “show our whole face”. Even our pain and distraction is welcome as signs of where we are in our personal process of becoming on that day. The embracing energy of acceptance and allowing permeates the circle. We intended to make a contribution to positive change while honouring the voices of all who participated. We intentionally used space and time as a precious resource and valued reciprocity and mutuality in our relationships. The process was more of a spiral than a linear progression as we used Indigenous ways of being together in dialogue and taking collective ownership of our work.
The view was a long term and patient one; the collective stance humble. Collectively, we hold an unfailing belief in individuals’ willingness and ability to change themselves, sometimes with the assistance of a “hand up” which is offered with high regard for their experience in that moment. We intend to do what we can. There was a distinct absence of ego driven competitiveness or a need for recognition and ownership. The work was truly spirit led and spirit assisted. A sense of hospitality and generosity prevailed as we cared for one another through the process. We invited each other over to our “home” perspectives with the enthusiasm of the best host or hostess. We trusted each other and the process enough to sit and visit with it until the next important realization bubbled to the surface and the next step became clear. Each individual and his or her sense of a need to protect “home territory” were honoured”.
From this project emerges a new way of understanding mental health and addictions as a human experience, best expressed as principles that apply to related programs, services and the systems supporting policy and program development and service delivery.
1. Honoring humanity and human experience
Honoring humanity and the common ground of human experience entails recognizing pain in all of its human dimensions, supporting the voice of those who often do not have opportunities for expression, and affirming the health and resiliency of individuals, families and communities
2. Centrality of connectedness and relationships
The centrality of connectedness and relationships to healing comes from traditional Aboriginal ways of knowing that view illness as a result of disconnection. Disconnection from self, family, community, the natural world and Creator at a spiritual level is the most fundamental problem. What is needed is a “soul to soul handshake” (S, Ottawa) as a foundation for relationships intended to help a person rebuild connections that serve as a bridge back into a connected way of living.
3. Valuing and learning from diversity
Rebuilding and nurturing mutual respect between all cultural groups and peoples is fundamental for a just and healthy society and for creating an effective mental health systemthat honors and integrates the best of the knowledge systems of each culture so they contribute to the whole.
“I realize that what happens in a culturally safe place is that you are open to new ways of thinking. With each person, I am making new meaning, Myself, I feel cultural safety when I am being treated with dignity, and I know its absence: when I am being treated as an object.”
– S, Ottawa
4. “Do no further harm”
To “do no further harm” is to honor that each person involved in relational engagement has vulnerabilities and past woundedness and as a fundamental principle, the intention is to not add to the burden of pain or trauma through negative relational experiences.
5. Patience
To have and express patience provides a quality to relationship that communicates that people are important and human connection takes time to unfold. Presence is not possible without patience to be with the other and wait for the next opportunity for deeper engagement to emerge. “Time is love. The most important quality one can give is time.” (SP, Saskatoon) Healing from the cumulative effects of intergenerational trauma and other major disruptions to wellbeing takes time. “Twenty-eight days after two centuries of trauma is not enough intervention for most people.” (SP, Whitehorse)
“You don’t just go for a month somewhere and all of a sudden expect everything to be ‘fixed’. It doesn’t work that way. Your history is a factor of who you are. You come from somewhere and need to figure that out.”
– SP, Saskatoon
6. Deep listening
“Following from patience is the ability to listen deeply to the other and hold space for their dignity to be protected and expressed. “It makes a lot of difference when somebody actually listens to people.”
– SP, Yellowknife
7. Radical acceptance
Valuing each person and accepting the way they are provides a place for meeting them there and moving from that point together. Valuing and acceptance is at the heart of non-judgment. This is not to say that all behaviour can or should be accepted and allowed in all circumstances. Unconditional love and acceptance and deep valuing can co-exist with setting limits to behaviour if needed.
“In my work with people because I’ve been judged a lot in my own lifetime, is just to practice acceptance and see that person as a human being, not with all the garbage that is in the way, but underneath that. Because that is who they are is what’s underneath there, not all this other stuff they’ve been clouded up with, through a lot of times, no fault of their own.”
– SP, Yellowknife
8. Reconnection
Illness is the result of disconnection and imbalance and therefore healing and recovery is founded on supporting reconnection with self, other, family, community and the natural world.
“Disconnection is from culture, from selfhood, from your own sense of agency; disconnect on a community level. It is pervasive. These are communities characterized by disconnection [within the community] and disconnection between the services and the population they are supposed to serve.”
– SP, Whitehorse
The balance of connections and the personal balance of mind, body, spirit and heart further the capacity for connection.
“So when they sent me back to my own people, they taught me how to take care of myself properly, they brought me back to praying, back to spiritual ceremonies and stuff like that. And they talked to me; they taught me how to be clean, how to survive, how to believe in myself, and how to feel more compete as a person.”
– SP, Yellowknife
9. Respect
Respecting the lived experience of care recipients, their family and friends and care providers is essential to honouring them and their process of becoming and healing in the world. A person can never know the full extent of another’s inner world but relational practice and ethical engagement can provide a safe bridge into a deeper and more authentic understanding of the other.
“Most of the family support work we do is trying to get from them how they see their world, how do they perceive it. It is all about hearing from them.”
– SP, Yellowknife
“People come because they feel safe…others have told them it is okay to come… they are not going to be judged or pathologized or labeled with the problem…they just need somebody to talk to and to know that they are actually present. To me if you can’t be present, go drive a truck. It is about balancing out the pain with the hopes, and to be able to hold both.”
– SP, Whitehorse
10. Collective healing
Building from existing family and community capacities strengthens natural social networks, rather than setting them aside. We need to honor peoples’ existing social networks and those they identify as family. Many one-to-one services disrupt family and community cohesion and fracture community connectedness. While we understand that not all relationships are always helpful or positive, we know that people are embedded in their social systems and healing needs to be supported at the collective as well as the individual level.
“We are dealing with a traumatized community. It’s not just where the individual is at; it is where the community is at. Government has made huge errors going in with guns blazing saying here is what we will give you, when the community didn’t invite them and hasn’t been consulted.”
– SP, Whitehorse
11. Community of practice
The idea of community of practice or community of care is important in supporting the ongoing growth and development of care providers – both paid and unpaid. Collaborative relationships within and between agencies provide for a spirit of working together creating attunement and synergy that better serves the people.
12. Strengths-based
Working from a focus on the strengths and capacities of a person or group is to affirm the positive and build from what is known to be strong. In Appreciative Inquiry this is known as seeking out the life giving forces, seeing them clearly and investing in them as a source of positive growth.
“What we do is development with them, capacity building. We get them to realize that they do have the solutions and that they are the ones who are the experts.”
– SP, Iqaluit
13. Relational attunement
Love and loving presence contribute to resonance between people. This is a deep and restorative form of connection. It is being in tune with the other and is a powerful antidote to fear, shame, and toxicity. Resonance signals the engagement of the heart and spirit, as well as the head.
14. Honouring boundaries
Honouring personal and collective territory is important as individuals learn and relearn boundaries and boundary setting. Part of defending boundaries is strengthening the ability to resist influences that are harmful. At a community level boundary setting is about protecting and preserving land as a steward.
15. Recovery mode
The recovery model has many helpful principles and practices including the use of peers and community agencies. It recognizes that recovery in addictions and mental health includes relapse, and often, movement onto further stages of recovery. Individual recovery needs to be supported by family and community level recovery. Policies and practices that govern the provision of programs and services should support recovery as a process at all levels. The recovery model used must be reflective of Indigenous ways of knowing, culture, values and healing methods.
“I have been working in recovery for years with people on mental health on an individual level, but there is recovery at a bigger level as well. There needs to be a sharing of power and resources, and the respect for where people come from. For the aboriginal communities, they need to be the drivers.”
– SP, Yellowknife
16. Nature as healer
Relating to and learning from nature is helpful in rebuilding connections.
“On the land is where everybody is connected together, in every aspect of our life; our physical, our mental, our emotional, our spiritual and socially too, because it’s all there together.”
– SP, Yellowknife
Working with the seasons can put a person in touch with the ebb and flow of life and assist in learning how to let go and move on with a new season, in harmony with the cyclical nature of life. Activities in the natural world can reawaken peoples’ stored cultural knowledge, sense of spiritual connectedness, and hope.
“I had a women’s mobile on the land program years ago that went from one region to the next. By the third week, the change in the women was just amazing. The results would not have happened within an institution in three weeks. No way. No way. This sort of thing with the land is more spiritual and grounding and there is more support for your emotional disarray that nature will provide for you. You don’t need words.”
– SP, Yellowknife
“If I had the funding, I would do an on the land type of treatment program. Once they go out on the land, our people are totally different people. When you are out on the land there are so many different aspects of the life that touches peoples’ lives. One of the findings of the evaluation of the program was how those women really felt more empowered when they were on the land…it made a huge difference in the dynamic.”
– SP, Yellowknife
17. Culture as healer
Culture and cultural continuity is fundamental to positive identity.
“The bottom line is to regain our culture. When we started this project, our own Board who are all Inuit gave it the title “rising up through your own culture.”
– SP, Iqaluit
“Part of using culture to support healing involves exploration of music, art and creative expression as therapy. One’s Mother Tongue is a powerful vehicle for connecting with culture.” On the land is where I regained my language…and learned all the knowledge about the traditional roles of men and women and children…”
– SP, Yellowknife
18. Prayers and ceremony
Prayers and ceremony are very important well-proven practices for healing within a cultural or spiritual context.
“One of the determinants of health we don’t see, is what I see as the driving or integral force for change inside the individual…your spiritual self…it is a vital component in change.”
– SP, Yellowknife
Fundamentals first
Food, clothing, shelter (housing), safety are important and foundational for healing as they meet the basic needs of human life.
Becoming and honouring human process
Ask people being helped how they are becoming and honour them as “works in progress”. The care provider offers stewardship in the care recipient’s process of healing, growing, and re-creating self.
Silence, Nature and “being with” as therapy
These practices acknowledge the therapeutic value of “being” not “doing”. For example, land based healing allows for periods of quietude on the land, time being with one another in small groups or around a fire where people may companion each other in silence, with little talking or activity. Taking time alone to connect with self, reflect on one’s inner dialogue and experience as part of healing is a well-supported Indigenous practice.
Culture as therapy
Well-proven cultural therapeutic practices have been showcased in the community-based projects funded by the Aboriginal Healing Foundation (AHF) www.ahf.ca, which was an outcome of the Royal Commission on Aboriginal People (RCAP) www.ainc-inac.gc.ca/ap/rrc-eng.asp.
“In terms of the RCAP, all the answers were already there…on how to do more culturally appropriate treatment, how to work cross culturally. The answers are all there; the blue print is there. It really boggles my mind, you know, what more needs to be done?”
– SP, Yellowknife
“I have always said that aboriginal people have to take ownership of their own people. And through the AHF we have had tremendous support from them recognizing alternatives to mainstream technologies so to speak, and to able to more key into the cultural part of our people.”
– SP, Saskatoon
Shared living
Showing people how to live and how to live together by doing it reinforces that “you embrace life by living it.” (S, Ottawa). Some people have forgotten how, so we need to live with them through life experience and help them relearn how to embrace life again.
Manage fear
It is important to identify and manage fear, due to individual vulnerability, or the emergence of relationship challenges either as expressed by the recipient of care or the care provider. It is working with our “soft spots” that promotes change.
No experts’ zone
When a person is an “expert”, there is no room for learning.
“They (women in a federal prison) reminded me that I was just the same as them. Just because I am a Doctor doesn’t mean I know it all and I would refer them to others who knew more than me. You are there more as a guide. Being humble, not acting as an expert is part of cultural safety.”
– S, Ottawa
Programming with options, multi-year funding, community driven
“These are the characteristics of some of the most effective programs; otherwise, enormous energy is consumed by continual fundraising. “I would say that 90% of the work I do for this center is keeping funds moving.”
– SP, Iqaluit
Metaphors are powerful ways of supporting human beings in understanding their experiences and the world around them. Shared metaphors help to create bridges of shared meaning and shared understanding.
Spiral as connected completed circles
Spiral is the metaphor for growth and human learning and change. Where each circle comes back around to join the next, there is a linking and an opportunity for connection, deeper understanding and insight. This set of ideas, arguably, is a more helpful model than the linear model in describing the process of change and healing.
Two Way Street
Relationship building and sharing time between people and within groups is a two way street with each person making an important contribution.
“This (building cultural safety) is a process, a learning opportunity, to build cultural competence that is a two way street. The people who hold onto the information are the FN, Inuit and Métis, and we have to be willing to share. The opposite is also true; the level of secrecy in government prohibits sharing. How do we build the intentional space in which people are safe to ask the questions?”
– S, Ottawa
“We have to negotiate a shared understanding of the problems that confront us.”
– SP, Winnipeg
“Aboriginal people can do a lot for all people if we are listening to their wisdom. We need to respect each other, have partnerships.”
– SP, Saskatoon
Walking Together
When people walk together, the best way to relate and see each other is to walk side by side with neither leading nor following.
“A phrase shared by a presenter at the Native Mental Health conference in 2009 was that our people would call this ‘walking together.’ It is the closest, simplest way to approach talking about cultural safety. What are the barriers to doing this? They have a lot to do with power, and being self-reflective about power relationships. In my case, I am a white psychiatrist, working with the Feds, and I need to be self-reflective about that.”
– S, Ottawa
“How can we grow it to a point where we can have a common ground, to be able to develop something that can be a complement to the rest of the Nation, from the aboriginal perspective? This is the struggling part of aboriginal healing…to be legitimately involved within the process. Where is that common ground? Where is the respect for one another?”
– SP, Saskatoon
Many choices and freedom to choose
Choice requires access to options and exercising choice can be a powerful process of defining personal preferences that fit with an individual’s healing path.
“The opening up of spaces for many choices for people is critical.”
– S, Ottawa
Return to the large human tribe
Our connections, as human beings are founded in our shared humanity and characteristics which support much common ground.
“With a focus on technology over empathy we are sub-dividing ourselves into smaller and smaller tribes, none of whom will be able to speak to each other. Rather than a technical approach, adopting a more holistic one characterized by compassion and empathy has the power to reconnect us.”
– S, Ottawa
All life matters
Foundational to respect is the honouring of all life, from the most humble plant, insect, fish bird or animal to the most dominant of species, human beings. By honouring all life, we honour our own lives and find compassion for each other.
“I was standing with an Elder and he was teaching me some things – all of a sudden his gaze went to the floor. I followed his eyes and saw this little ant walking into the circle. Alex says: “See the ant?” and I say “yeah”. He said “He is my brother. He is no better that I and I am not better than him. When we as humans can think that way, we will have the peace we seek.” That has transformed my relationship with all people and all of creation. … I don’t believe we can help people on their journeys of healing if we are one up and one down.”
– S, Ottawa
Humanized and humanizing relationships
Healing is about creating opportunities for each human being to become all they can be which requires approaches that are humanized and whole, not fragmented and mechanical.
“It takes confidence to speak from your heart, comfort with who and what you are, to show your face. It is important to build on Aboriginal perspectives of a ‘good way’ and Friere’s thoughts about being “fully human” in order to participate in humanized societies that counteract dehumanizing forces.”
– S, Ottawa
“The more we work, the more we understand; it is about building a relationship with another human being.”
– SP, Saskatoon
Knowing self – knowing other in context
To learn to know another, we must know ourselves and much of what we know and understand grows out of the context of our lives. The Elders tell us that we need to know who we are and where we come from in order to move on in life.
“You don’t know me and how can you work with me if you don’t know me?’ and ‘You don’t know me but you get to define me and by defining me you get to decide what happens in our relationship’ are quotes from an Aboriginal man that point the way for a human relationship of shared ‘knowing’ that is fundamental to ‘working with’ someone to assist in recovery. Power inequities are fundamental to any human relationship and the systemic and relational power dynamics must be consciously managed.”
– S, Ottawa
Know what you stand for and change self
In order to know “your side” and differentiate it from the “oppressor”, self-discovery and awareness is necessary. To hold on to where you stand and what you stand for as you continue to change yourself is a very powerful way to catalyze change. The Elders also point us to the idea that it is people who change, not systems. People do not relate to systems, they relate to the people representing the systems.
“The Elders that guide me tell me to not side with the oppressors, to change them. We need to do what we need to do to change ourselves and they will come around.”
– S, Ottawa
Circles within circles
Inner circles of intentional relational creativity and generativity provide the foundation to take ideas out to a broader circle in which there may be less intentional awareness and more diversity of ways of knowing, relating and working.
Ripple effect
Listening to and understanding each other will help guide where and how we throw the stone and what size and shape we should use to create intentionally corrective ripples.
“The image that comes to mind is the circles from a stone being thrown into water and gradually widening those circles. In terms of knowing where to go and how to get there, we need to listen careful and make sure we understand. Listening and acting on what we hear based on where we are at in the process are important.”
– S, Ottawa
Speak the truth in love to people
Human history has shown us many times over that more positive change comes from love than from fear and anger. Love generates openness/expansion and fear/anger generates resistance/contraction. Fundamental to any positive change is finding the many truths that we all bring and speaking them to each other with loving presence and within a mutually created ethical space.
“We need to speak the truth in love to people. And there is no solo advocacy; it’s about collective advocacy”
– S, Ottawa
Intentional disruption is good
Complexity theory tells us that a complex system will not change unless there is an intentional disruption in the patterns that hold the system in current ways of operating. Cultural safety and relational practice may provide the foundation for a set of intentional interventions to modify the complex mental health and addictions system.
“It (cultural safety) is a practice that at some level disrupts. Culturally safe practice would disrupt the status quo; there would be a broader effect, some action-ability. One thing that is different about it is that it is meant to disrupt the system.”
– S, Ottawa
“When do I get to say, it’s wrong? Where do you ethically, spiritually and morally draw the line and say I can’t go past that line?”
– SP, Yellowknife
Healing and recovery as learning and growth
Healing and recovery is a human process that requires acquiring new insights, new knowledge and skills that support us in moving on to the next stage of becoming. An experience of safety is fundamental to being open to new learning.
“When you enter a circle and it is safe, it permits whatever in you that is related to what others are saying to surface, and new understandings to emerge. Safe circles are where we continue our journey of learning.”
– S, Ottawa
Intuition, wholeness and change
Intuition is a source of connection to inner guidance of many forms. Our spiritual selves know what our wholeness looks like and guidance from that centre helps us to return to the wholeness that is unique to each person. Healing often requires change and reintegration, reconnection with all four aspects of being – mind, body spirit and heart. That inner wholeness provides the base from which relationships with family, community, culture and land can be strengthened. Each individual in sharing stories of healing and change inspires and guides others.