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

Summary

Objective 1: Research and Analysis of Cultural Safety

This objective has been accomplished through the development of two research discussion papers on cultural safety and social inclusion, focus group discussions across Canada with Aboriginal and non-Aboriginal consumers, service providers and family members/caregivers, and a national symposium on cultural safety. The project partners have also co-produced a complimentary professional DVD documentary focusing on cultural safety and relational practice entitled: Glimpses of Light.

The first research discussion paper, prepared by Barbara Everett, PhD, is called Belonging: Social exclusion, social inclusion, personal safety and the experience of mental illness. The paper provides a review of the research literature on social exclusion, inclusion, personal safety and the experience of mental illness, as well as an overview of various government policies aimed at promoting the social inclusion of marginalized people. The second research discussion paper was prepared by Victoria Smye, PhD, RN, Annette J. Browne, PhD, RN and Viviane Josewski, MHSc. , and it is entitled Supporting the Mental Wellness of First Nations, Inuit and Métis People in Canada: Cultural Safety– A Research Discussion Paper. It provides an in-depth overview of cultural safety: what it is, how it has evolved, how it relates to cultural competence, why it is needed, and what it brings to mental health and addictions services for FNIM people. The paper also includes a series of recommendations for engaging cultural safety as a concept to work for social justice in mental health and addictions care.

The focus groups involved discussions with 246 people in eleven cities across Canada including 155 service providers, 86 consumers and five family members. One hundred forty-two (142) of the participants were Aboriginal and 104 were Non-Aboriginal. Discussions revolved primarily around the following questions: why people access mental health and addictions services, how people access the services, what happens when they access services, what makes people feel safe or unsafe when accessing services, and what needs to be improved about existing services, with regard to models of service provision, education and training of service providers and policy directions.

The MDSC and NMHAC convened a two-day symposium in Ottawa, attended by service providers, consumers, representatives from mental health NGOs, representatives from the Mental Health Commission and funders. The participants engaged in structured discussions to grapple with the following questions: what constitutes culturally safe practice and what conditions are required for it to take root and thrive; do cultural and social institutions need to be restored or reformed and if so, how; what do participants know that would contribute to advancing excellence in relational practice; do we envision a relationship between social exclusion, peer support and relational practice; who do we need to target and what do we need to convince them of?

Key Findings from the Research

A number of common themes have emerged from the research done for Building Bridges 2. A review of these themes and an analysis of their significance and implications for service delivery and policymaking appears below, and this has been used to inform the proposed planning framework on cultural safety.

The Need to Belong

What is evident from the research is that everyone—Aboriginal, non-Aboriginal, consumer, service provider, family member-needs to belong. That is to say, everyone needs to be part of a social group within which they feel safe and at home. This is a fundamental human need and a key determinant of health and well-being. Social isolation and exclusion have been shown to lead to increased rates of premature death, depression, and higher levels of disability from chronic disease, while belonging to a supportive social network makes people feel cared for, valued and esteemed. This has a powerful protective effect on health and mental health.1 For example, social support and social cohesion serve to reduce the physiological response to stressful circumstances which, if not mitigated, can lead to poor health outcomes.2

Many people experience this sense of belonging within a cultural community, within which they forge an individual and cultural identity. Culture has been defined as…a dynamic and adaptive system of meaning that is learned, shared and transmitted from one generation to the next and is reflected in the values, norms, practices and ways of life and other social interactions.3 It is the foundation of individual and collective identity and its erosion can negatively affect mental health and wellbeing.4 Language is a conveyor of culture5 and the means by which knowledge, skills and cultural values are expressed and maintained.6

The Experience of Social Exclusion, Stigma and Discrimination

Unfortunately, people with mental health problems and addictions are often socially excluded, isolated, and subjected to stigma and discrimination. They are viewed as “other” by mainstream society and, as a result, they are rejected, dismissed, disempowered and unheard. As Dr. Everett points out in her discussion paper:

… it is easy to see that many people feel that they don’t belong. A personal sense of being excluded, of being different or of not being valued is harmful to the individual and this harm is only increased when the active dimensions of stigma and discrimination enter the mix, meaning that those who do belong (mainstream society) fear or even hate you for being who you are (or, better said, who they think you are) and act in ways to ensure that you have limited opportunities, restricted access to the resources and rights that others enjoy, and little or no opportunity to protest poor treatment or to make your voice heard. People with mental illness and their families know all too well the negative effects of stigma and discrimination and the pain of feeling excluded from their communities.

Unfortunately, stigma and discrimination are often perpetuated by service providers as well, this can deter people from seeking help. Indeed, it can cause further harm to people who are already wounded and vulnerable. This point was made in a powerful way by a number of eastern focus group participants.

We need professionals who treat you like a human being.
– Consumer, North Bay, Ontario

They are shown a lot of disrespect and people will not go to the hospital, even if they are very ill, because of the way they are treated. If we had a more humane, respectful system and no stigma from professionals, people would be more likely to go for help.
– Family Member, Montreal, Quebec

They process people like numbers. If you have cancer they will hold your hand; if you lose your foot they will be there to help you learn to walk again. If you have mental health issues, they just send you out on the street – you get no support.
– Aboriginal Consumer, Halifax, Nova Scotia

Social Exclusion Plus: the Aboriginal Experience

Aboriginal people with mental health and addictions issues are subjected to the same social exclusion, stigma and discrimination experienced by all consumers. When these are combined with racism and racist stereotyping, as they often are, they become a toxic brew of negativity and pain for Aboriginal people seeking help.

I’m lucky that I’m not on pills or alcohol; but when we First Nations people go for services, they assume we are all alcoholics. One doctor asked me if I ever drink, which I did, occasionally and moderately, and he put in my chart that I was an alcoholic.
– Aboriginal Consumer, First Nation, New Brunswick

When people are struggling with multiple challenges, all of which are stigmatized (e.g. mental illness, addiction, being part of a racialized group, being poor), the outcome is apt to be even worse.

To be honest with you, I think a lot of it [the way I was treated by the system] has to do with being a person of colour. Within the mental health system, if you go for help and you have any type of drug history, they don’t believe you. They don’t believe that you really want help
– Aboriginal Consumer, Halifax, Nova Scotia

All of this is magnified and confounded by the continuing impact of colonization, including the loss of culture and trans-generational trauma and grief. As the Western Focus Group Report points out:

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. Similarly, the Cultural Safety Report notes that: Cultural discontinuity has been strongly linked to the disproportionate problems of Aboriginal communities with depression, addictions, suicide and family violence.7

The residential school experience, in particular, has left Aboriginal people with a terrible legacy by creating stress and trauma while damaging cultural identity and cohesion, key factors in support of mental health and wellbeing. As explained in the Cultural Safety paper: 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.8 ..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”.

What Doesn’t Work: the Inadequacy of Mainstream Services for Mental Health and Addictions

In their present form, most mainstream mental health and addictions services are poorly constructed to meet the complex needs of Aboriginal people with mental health and addictions issues. Indeed, as reported in the Cultural Safety paper, Aboriginal people tend not to use mainstream services and when they do, they are often noncompliant with or drop out of treatment altogether. This appears to be due largely to the narrow biomedical perspective of mainstream services, which is based on the values, beliefs and assumptions of the dominant culture; the inherent power imbalances between service providers and consumers which occur as a result of these values, beliefs and assumptions; and closely related to these, the fragmented nature of service provision, i.e. the separation and funding disparities of mental health and addiction services. That is to say, services are provided through distinct, disconnected and differently funded service streams such as physical (medical) health services, medical mental health services, non-medical mental health services, addictions services, peer support and self-help initiatives, basic needs services such as income support and housing, etc. For Aboriginal people, this approach to service provision is counter-intuitive and not suitable for meeting their needs.

The white man’s way is to separate things into categories and we see things as part of a whole.
– Aboriginal Consumer/Service Provider, Halifax, Nova Scotia

Why are we slicing and dicing our health? …Into mental health, physical health? It’s all health. We chop things up and label other people and ourselves, it’s not helping anybody and it never has. We need to look at this as a society as a whole….We have to stop thinking of people as broken; we’re not cars. My mental, physical, emotional and spiritual health are all connected; we’re living the medicine wheel.
– Aboriginal Consumer, Halifax, Nova Scotia

Non-Aboriginal consumers also report significant dissatisfaction with mainstream service models. They too want to be seen and treated as whole persons, who have problems that have emerged within the context of a life lived. They do not want to be reduced to a disorder for which the only prescription is some type of psychiatric medication.

Everything can’t be fixed with a pill.
– Consumer, North Bay, Ontario

When mainstream services are accessed, they may do more harm than good: that is, they often perpetuate stigma and discrimination and re-traumatize consumers. Unfortunately, it seems that disrespect and condescension from service providers are more the rule than the exception, and service providers themselves acknowledge this.

We need professionals who treat you like a human being.
– Consumer, North Bay, Ontario

Addictions and mental health services, even health services generally, they are certainly lacking in sensitivity. To be on the receiving end, where you are treated dismissively – the provider knows best, isn’t interested in your views – it’s desperately condescending.
– Service Provider, Halifax, Nova Scotia

In addition, because these services operate in silos, disconnected from other services and supports, many people are unaware of the range of service options and do not know how to navigate the system of care. Due to funding disparities and the lack of coordinated models of care, most consumers will first access medical services. As a result, treatment tends to be limited to medication and/or hospitalization. There is little continuity of care for people seeking other services or supports or even within the mainstream service system.

I don’t think the mental health system here has ever understood inter-disciplinary team concept – there is no holistic care – they don’t treat the whole person. The psychiatrists are not recovery focused; they don’t ask how people are doing with their lives. They just ask “How are you sleeping? How are the meds?” And that’s it.
– Service Provider, St John’s Newfoundland

…every time I saw a new person, it went to zero – I had to retell my story, they had to start a new file, no continuity of care, so no one seems to have the “big picture”; my file was often not forwarded to the new providers, and when it was, it seems the new people don’t look at it.
– Consumer, Halifax, Nova Scotia

Ironically, despite the limited capacity of mainstream services to meet the needs and support the recovery of consumers (Aboriginal and non-Aboriginal), they are often difficult to access.There are long waiting lists for services and in rural and remote areas, people may have to travel great distances to access services.

The only way to get in [to mental health services] is if you threaten to kill yourself….And even then you will have to wait.
– Consumers, North Bay, Ontario

Mental health and addictions services are chronically underfunded—the “poor cousins” of health services—due to the ongoing stigmatization of mental health and addictions problems.As a result, mental health service providers are made to feel inferior to their counterparts in the mainstream health system.

The overall system pays some lip service to what we do, but people working in mental health are at the bottom of the totem pole; we need to be socially included as care providers also.
– Service Provider, Halifax, Nova Scotia

What Does Work: Holistic and Relational Care

Consumers need holistic and relational models of care to develop a sense of belonging and to support their recovery from mental health problems and addictions. These problems do not arise in a vacuum; they emerge within the context of each person’s life history, individual strengths and challenges, current life circumstances and stressors, and they are often inter-related. Healing cannot happen unless people feel safe. People feel safe when service providers view them as whole persons rather than disease entities and treat them with compassion, empathy and respect. Unfortunately, mainstream services do not function in a holistic way and current approaches to training health professionals seem to be lacking in this regard.

The doctors don’t understand and they don’t see all the linkages and the underlying factors that cause the problems. When you clear up the pain and suffering you dealt with, that’s when you start to feel better.
– Aboriginal Consumer, Sudbury, Ontario

These are communities characterized by disconnection (within the community) and disconnection between the services and the population they are supposed to serve. 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.
– Participant, Whitehorse

Good ones [service providers] are about inclusion and understanding you are an expert about your own experience. These individuals are certainly trained, but they are not necessarily trained in human interactions, so if they’re good, it’s usually because of their personality, not their training.
– Consumer, St. John’s, Newfoundland

For Aboriginal people, the concept of balance is central to understanding why people become ill and how they recover. As the Western Focus Group report points out: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. The balance of connections and the personal balance of mind, body, spirit and heart further the capacity for connection.And, as noted in the Cultural Safety paper: 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 “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”.

Holistic models of care for mental health and addictions are rare, however, for a variety of reasons:

  • inadequate funding for mental health and addictions services generally, due to stigmatization and discrimination;
  • funding disparities that favour the biomedical system over alternative approaches (including but not limited to psychotherapy, peer support, self-help and traditional Aboriginal healing approaches) because of the dominant culture’s lack of respect for services and supports deemed to be “unscientific”;
  • the lack of understanding and attention to the broad social determinants of mental wellbeing, within most mainstream models of care. These include culture, socioeconomic status, social support, stress, etc.;
  • the artificial distinction in policy and practice between mental health problems and addictions;
  • the fragmentation of services and lack of service coordination within the mainstream service system, due to the “siloing” of these services; and
  • legislative and jurisdictional issues that restrict the access of Aboriginal people to appropriate services and supports.

Getting to What Works: Cultural Safety, Relational Practice and Complementary Approaches

For Aboriginal people, the concept of cultural safety is central to developing effective models of holistic care and relational practice. 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. As the authors of the Cultural Safety paper say:

Cultural safety…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. … it 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.

Relational practice is integral to cultural safety and it is defined as follows:

[Relational practice]…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. 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 socio-environmental limitations” influence health and well-being, the illness experience, decision-making and the ways in which people manage their experiences. (Cultural Safety paper)

These concepts are of great value for transforming service delivery models and restoring good ways of providing mental health and addictions services for (and with) Aboriginal people in Canada. As an example, the Western Canada Focus Group report shows how ideas of cultural safety and relational practice can lead to holistic and effective models of service delivery for Aboriginal people.

“…and so you know housing is a necessity…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…”
– Participant, Yellowknife

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.
– Participant, Yellowknife

We would argue, moreover, that the same concepts are an excellent starting place to undertake a critical examination of mental health and addictions services for non-Aboriginal people, with an emphasis on understanding the values, beliefs and assumptions that underpin these services and influence their outcomes, and with the objective of developing new and better approaches to meet peoples’ need and promote healing and recovery. As Dr. Smye said in her address to participants at the Symposium:

Cultural safety… is a concept to help us think about and frame things and move to a place of working relationally in this country. I want to underline that relational practice is not simply about inter-personal relationships – being nice and kind, caring and compassionate. It’s about understanding ourselves and the care we provide in relationship to the contextual features of our lives, including where we live, how connected or disconnected we are from our past and how we are all deeply connected in many ways.

When I speak relationally I am speaking not just about being nice… Relational practice calls for vulnerability. That is our challenge, because many people are afraid of being vulnerable. I was taught in a tradition of keeping boundaries very clear, of being careful, not sharing. I would say to you that we have to learn how to shift practice to say it’s OK to know and to be known. And we can be safe in that.

These concepts speak to us all—Aboriginal, non-Aboriginal, consumer, family member, service provider or policy maker. We all need to critically reflect on our culture: on what it values and devalues, what it believes and assumes, and what these bring to the table and leave behind for mental health and addictions services. The capacity for critical analysis can be learned, and it has been conceptualized as the highest level of health literacy, as shown below in an excerpt from a report on mental health literacy in Canada.

Critical mental health literacy involves the development of skills to critically analyze and use information to mobilize for social and political action, as well as individual action. Social action can be directed toward changing public policy and modifying social and economic determinants of health. Enhancing critical mental health literacy supports collective empowerment and the development of social capital. Because improving critical mental health literacy exerts influence on determinants of mental health, it can result in benefits to mental health at a population level. Such initiatives are particularly important for marginalized groups suffering from a high incidence of mental health problems related to social and economic conditions, such as Aboriginal people and immigrant populations.9

The symposium participants also emphasized the need to critically analyze the explicit and implicit values and beliefs of the dominant culture, to understand how these underlie decisions about policies and practices that shape health services, and to undertake collective action to “bring others into the circle.”In addition, they agreed thatindividuals need to reflect on their own assumptions and biases and on how these shape their interactions with others.Participants spoke of the need to “walk the talk”—to lead by example, to effect change from the bottom up, to adopt a critical lens of self-reflection and to open oneself to vulnerability.

Creating the Best of Both Worlds

People who have been stigmatized and excluded have been harmed in fundamental ways. They need experiences of safety in order to be able learn, work, engage and participate. Creating personal safety and security is an essential first step in the process of recovery. This includes physical safety, relational safety and emotional safety. (Belonging discussion paper)

For Aboriginal people, it is clear that cultural safety and relational practice are valuable concepts for moving mental health and addictions services in the direction of models of care that meet their needs and within which they feel safe, accepted and supported. For most, this will involve a restoration of healing practices that are grounded in the Aboriginal worldview and that emphasize wholeness and balance. For most, it will also involve autonomy and empowerment in terms of service delivery.

What’s important too, and I know this from experience…. the services don’t have a cultural component. We need to start delivering our own services, and not just using the orthodox way but using a medicine wheel approach with our own ways of doing things. Otherwise, it just becomes the regular psychiatric/mental health system with a brown face. The white man’s way is to separate things into categories and we see things as part of a whole.
– Aboriginal Consumer/Service Provider, Halifax, Nova Scotia

We would propose further that mainstream services, as currently configured and delivered, do not meet the needs of non-Aboriginal consumers. Non-Aboriginal Canadians need to be viewed as whole persons. They need to feel valued and supported. Their mental health and addictions problems have a history and a context, and they are inter-related. Everyone needs a safe place where healing can take place. Everyone needs to belong.

The western model of healing views mental illness and addictions through a narrowly focused biomedical lens which characterizes these problems as residing within the individual, usually in terms of a brain-based disorder. This perspective is limited, insufficient, and at times, harmful.It is our view that western approaches to healing could benefit significantly by adopting a more holistic approach to health and healing, and the Aboriginal community has a great deal to offer in this regard.

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. (Western Canada Focus Group Report)

Our program activities are holistic; a blend of contemporary and traditional services to meet the complex needs of our urban aboriginal population. We like to say we take the best out of both worlds.
– Participant, Winnipeg

This work needs to be done at the level of the collective, although it begins with the individual through a process of critical self-reflection; this leads to a critical analysis of the structural inequities and biases inherent to our health care systems and a shared commitment to social action for change. As the Symposium participants put it:

It is crucial to overcome the dichotomous approach of ‘we’ versus ‘us’, to seek commonalities in worldviews and find the join that will create alliances. This will not only promote cultural safety as the outcome in terms of policy, education and practice but make the process of change culturally safe by “not placing the burden of change on the individual”.
– Symposium Participants

Summary of Key Themes

  • Restoring a sense of belonging through social inclusion and support is critical for supporting recovery from mental health and addictions problems; stigma and discrimination result in social exclusion, which exacerbates the problems and deters healing and recovery.
  • Stigma and discrimination from mainstream service providers needs to be addressed.
  • Mainstream mental health and addictions services are often inadequate for and underutilized by Aboriginal people.
  • Cultural continuity is a key factor in promoting the mental health and wellbeing of Aboriginal people and reconnecting with culture has a healing effect.
  • Mainstream services are also inadequate for many non-Aboriginal consumers. The services are underfunded, hard to access, fragmented, and limited in scope. Consumers’ experiences with services are often stigmatizing and harmful. Funding is targeted primarily to biomedical approaches, which are insufficient to meet the needs of consumers.
  • Concepts of cultural safety and relational practice are particularly valuable for Aboriginal people, because they encourage health care providers, policy makers, 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; and to recognize 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. (Cultural Safety paper).
  • These concepts are valuable for non-Aboriginal people as well, because they provide a way to understand why health service systems function as they do and what needs to be changed so that consumers feel safe and supported and healing can take place.
  • Holistic and complementary approaches need to be developed for mental health and addictions care; approaches that take the best from both worlds (western and indigenous).

Objective 2: Development of a comprehensive planning framework on cultural safety

1 Wilkinson, R. & Marmot, M. (Eds.) (2003) Social determinants of health: The solid facts. Copenhagen: WHO. www.who.dk/document/E81384.pdf

2 Ibid

3 Kreuter, M.W. & McClure, S. (2004) The role of culture in health communication. Annual Review of Public Health. 25: 439-455. In Culture and Language as Social Determinants of Health, 2009-2010, The National Collaborating Centre for Aboriginal Health, University of Northern British Columbia.,

4 Kirmayer, L.J., Brass, G.M. & Tait, C.L. (2000). The mental health of Aboriginal people: Transformations of Identity and community. Canadian Journal of Psychiatry. 45(7):607-616. In Culture and Language as Social Determinants of Health, 2009-2010, The National Collaborating Centre for Aboriginal Health, University of Northern British Columbia.

5 Ibid

6 Culture and Language as Social Determinants of Health, 2009-2010, The National Collaborating Centre for Aboriginal Health, University of Northern British Columbia.

7 Chandler & LaLonde, 1998; RCAP, 1995 in Smye et al, 2010.

8 Brasfield, 2001; Kirmayer et al., 2003; 2009a; Söchting, Corrado, Cohen, Ley, & Brasfield,

9 Bourget, B & Chenier, R. (2007) Mental Health Literacy in Canada. Canadian Alliance on Mental Illness and Mental Health, Ottawa, Canada. Dr. D. Nutbeam introduced the concept of health literacy as a set of cognitive skills that develop in stages and reach their highest expression as critical health literacy: Nutbeam, D. (September 2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 15(3): 259-266.