https://www.infirmiere-canadienne.com/blogs/ic-contenu/2023/01/23/connaissances-autochtones-maladie-mentale
Reforms needed to undo oppresive colonial structures that have led to inequity & poor health
By Gabriel Barrington-Moss
January 23, 2023
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The literature strongly supports a moral imperative to explore, understand and operationalize equity-driven health policy addressing Indigenous mental illness. The subsequent development of substance use disorder in this population is nearly always rooted in a history of colonial oppression, erosion of culture knowledge and ways of healing and, notably, childhood trauma.
It has been well documented that health disparities have overarching consequences on not only Indigenous people’s health, but also their feelings of holism (Owais et al., 2022). Overwhelmingly, we can see the need for political, health and social policy reform that will specifically and directly deconstruct colonial social structures that are at the heart of living under the oppression of inequity. To achieve this end, the development of culturally specific mental health and addictions care and treatment for the Indigenous Peoples of Canada is required. Such health reform must encompass the current and specific needs of Indigenous people living in both rural and urban settings.
Understanding the roots of Indigenous mental illness
Indigenous people in Canada have on average a life expectancy that is 12 years less than that of non-Indigenous people. Many of the causes of early mortality include treatable chronic illness such as mental illness and subsequent addictions and suicidality (Walker, Harris, Thomas, Phillips, Stones, 2018). The following seminal statement, articulated by de Leeuw, Greenwood and Cameron (2010), illuminates the gravity of the historical and contemporary Indigenous lived reality: “Loss of language and cultural fluency, the outcome of assimilative policies resulting in practices such as residential schooling, are expressed as broad scale cultural trauma and lack of social cohesion that translate into diminished resiliency, lessened fortitude to overcome addictions, and higher rates of family violence” (p. 285). This statement cannot be unseen. Attaching “personal” health practices and behaviours to poor health outcomes in Indigenous Peoples is no longer an acceptable narrative and will not allow constructive and restorative reconciliation.
The literature strongly supports a moral imperative to explore, understand and operationalize equity-driven health policy addressing Indigenous mental illness. The subsequent development of substance use disorder in this population is nearly always rooted in a history of colonial oppression, erosion of culture knowledge and ways of healing and, notably, childhood trauma (Gould, MacQuarrie, O’Connell, & Bourassa, 2021; Noronha et al., 2022).
Understanding the linkages between colonialism and mental illness is complex because they are often generalized as being homogeneous byproducts of intergenerational and historical trauma (Nelson & Wilson, 2017). Through the homogenizing process, mental illness and addictions are disconnected from the subtle nuances of individual experience, areas of strength, concepts related to resilience, etc. They are often reduced to an epistemological perspective of cultural “difference” rather than viewed as connected to the larger social, political and exclusionary processes that direct mental wellness and healing.
Illuminating health disparities and inequities
Rather than focusing on the cultural differences argument, contemporary research efforts are illuminating an alternative narrative that is much more challenging to digest because its reality would require large-scale, macro-level interventions related to health inequalities and their antecedents. Given the linkages between poor mental health and the experience of health disparities and inequities, it is perhaps not surprising that Indigenous people in both Canada and other nations experience disproportionately high rates of mental health-related illnesses.
Mental illness in Indigenous communities has most predominantly come in the form of chronic suicidality, alcoholism, violence of all forms, internalized racism, post-traumatic stress disorder and major depressive disorder (de Leeuw et al., 2010). According to the World Health Organization, Indigenous mental illness has been a long-standing endemic that is related to economic inequities, low levels of educational advancement, a strong sense of internal identity conflict, and federal dependence for welfare and well-being (Cianconi, Lesmana, Ventriglio, & Janiri, 2019). Cultural and ethnic erosion has also been strongly connected to an increased risk of suicide among Indigenous youth as they have migrated away from traditional lands and practices into forced settlements and artificial social structures (Cianconi et al., 2019).
It is important to recognize that mental illness is a barometer or litmus test that directly demonstrates the outcome of stress and distress on an individual’s or a community’s current level of coping and resilience. The alarming rates of mental illness in Indigenous communities across Canada underscore a culture that has had its coping strategies and systems taxed to such a degree that the ability to see a clear and unobstructive pathway toward holistic health likely feels insurmountable.
Honouring the historical context
When contemplating strategies and actions that a community-led health promotion initiative could design and ultimately provide, a true measure of success can only be determined when an initiative, in its entirety, is viewed through an Indigenous framework to health and mental wellness. According to Marsh, Coholic, Cote-Meek, and Najavits (2015), the concept of “honouring the historical context” is an essential ingredient in creating a health promotion strategy that would be effective at meeting the identified community need. This concept helps us understand where the community has come from, which is an essential step in understanding where it will endeavour to go.
Although a substantial foundation of health promotion research and intervention programming is available to reference and build upon, this research and program development has classically been framed using a non-Indigenous lens, leading to suboptimal outcomes (Walter et al., 2020). Indigenous knowledge (IK), science, traditional ways of healing and enlightenment and land-based identity will be essential building blocks in creating a collaborative and representative framework for health promotion design (Gould, MacQuarrie, & Bourassa, 2021).
Within Indigenous communities, a strong sense of self has acted as a protective factor.
Promoting Indigenous holistic health and mental wellness, with a particular focus on mental health and addictions, must occur via a ground-up or upstream initiative. The rationale for this is that Indigenous Peoples have had their cultural ways of being eroded and dismantled by their lived experience under generations of colonial assimilation (Walter et al., 2020).
Lacking a clear sense of identity, culture and position in the world can leave an individual untethered and vulnerable to an identity crisis; this, in turn, may significantly marginalize their ability to be resilient in the face of stress and distress. Self-identity is grounded and developed in the home environment. Children are vulnerable to the adverse life experiences that can present themselves when maturing in a home that lacks the stability and grounded nature of family members who have a strong sense of self, worth and place in the world (de Leeuw, Greenwood & Cameron, 2010). Within Indigenous communities, a strong sense of self has acted as a protective factor against mental illness and addictions and has sustained the individual and the community during times of distress (Greenfield & Venner, 2012).
Centring Indigenous knowledge
Reconnection to the Indigenous worldview, alongside culturally centring Indigenous communities in their rich connection to the land, history and spirit world, will be essential as a starting point for responsive mental health promotion. Achieving person-centred positive outcomes can be enhanced by framing health promotion through a lens of IK and ways of sustainment (Walters et al., 2020). Approaching health promotion, specifically mental health promotion, through a perspective that the individual and the community are best situated to share their narrative where the challenges and opportunities lie enhances the likelihood that the designed intervention will be responsive to the specific needs of the target group (Stanley et al., 2020). Creating a culturally centred health promotion initiative, based on IK, would allow for the “unpacking” of historical contexts, a focus on the contemporary “what is,” and a discerning eye for “what could be” in a future open to healing and prosperity.
Illumination and Elevation
Focusing on IK as the foundation upon which the health promotion initiative would be based — that is, a mental health-based strategy called “Illumination and Elevation,” which focuses on strengthening Indigenous self-identity — would aim to deconstruct the historical and contemporary barriers to Indigenous development of identity and, by proxy, mental health and mental wellness. Working directly with the Indigenous community identified would allow for a collaborative effort whereby Indigenous Elders and knowledge experts would be integral in shaping the community assessment, intervention development, implementation of the intervention, and the measurement of success (Stanley et al., 2020). Celebrating the IK held by tribal Elders and experts reduces the barriers to community “buy-in.” Such is the case when Indigenous community members connect with a message being shared by a trusted and respected source. Connecting with the message and seeing the knowledge holder as an expert in one’s history and story are essential when developing health promotion interventions. Indigenous Elders are knowledge holders who possess the lived experience of health disparities, particularly mental health disparities.
Illumination and Elevation are health promotion initiatives designed to address the inequities in Indigenous health (Greenfield & Venner, 2012; Stanley et al., 2020). Within an identified Indigenous community, these health promotion strategies would focus on two important avenues for promoting mental wellness and individual/collective capacity and preventing situation crisis from becoming chronic mental illness.
Illumination
Within the initiative, “Illumination” would focus on the community collective led by Indigenous tribal Elders and co-facilitated with mental health experts. The process would include learning of the journey through the creation and discovery of historical narratives. The program objective of Illumination would be twofold: first, to uncover historical wounds, both personal and community-wide, that are contributing to present-day stress, distress and, ultimately, mental health disparities, from a place of understanding and self-compassion, and, second, to uncover areas of strength and opportunities to capitalize on those strengths.
As explored by Stanley et al. (2020), it will be critical that the Illumination group/individual sessions be led by trusted community Elders owing to “mistrust of research and researchers by many Indigenous Peoples, rooted in past ethical abuses” (p. 2155). Affirming the legitimacy of the researcher in authentically representing a desire to promote mental wellness will need to be developed through the gradual etic (cross-cultural) involvement with community members, under the endorsement of the tribal Elder(s). IK, and the opportunity to unpack the thoughts and emotions connected to the Indigenous lived experience within this context, would allow the individual and the community to begin to develop an understanding of the “why” behind the impacts of intergeneration trauma and disorganized identity development (Stanley et al., 2020). Illuminating the why allows the individual to begin to recognize that their lived experience and reduced personal capacity to maintain mental wellness are byproducts of colonial trauma and forced federal dependence rather than the result of personal weakness or a lack of fortitude.
Elevation
Elevation within this health promotion initiative would focus on mobilizing the inherent personal and collective strengths, identified under Illumination, and capitalizing on these strengths to elevate and build resilience — key factors in mitigating the development or exacerbation of mental illness (Greenfield & Venner, 2012). Specifically, Elevation would be led again by tribal Elders and mental health experts, with the purpose of reframing negative thoughts about the personal and the collective self to a narrative related to the areas of strength identified under Illumination. In essence, the group would be led through capacity-strengthening narratives and activities that would enhance areas of strength, such as personal strengths related to skill sets, interests and community strengths such as land situation, tribal knowledge, wisdom and access to healing and self-sustaining practices.
Building capacity
In keeping with sustainability principles and a “doing with rather than doing for” perspective, building capacity within the community to elevate holistic health will enhance Indigenous mental health by illuminating truth and standing upon that truth to elevate personal awareness, identity and strength.
References
Cianconi, P., Lesmana, C. B. J., Ventriglio, A., & Janiri, L. (2019). Mental health issues among Indigenous communities and the role of traditional medicine. International Journal of Social Psychiatry, 65(4), 289–299. doi:10.1177/0020764019840060
de Leeuw, S., Greenwood, M., & Cameron, E. (2010). Deviant constructions: How governments preserve colonial narratives of addictions and poor mental health to intervene into the lives of Indigenous children and families in Canada. International Journal of Mental Health & Addiction, 8(2), 282–295. doi:10.1007/s11469-009-9225-1
Gould, B., MacQuarrie, C., O’Connell, M. E., & Bourassa, C. (2021). Mental wellness needs of two Indigenous communities: Bases for culturally competent clinical services. Canadian Psychology, 62(3), 213–236. doi:10.1037/cap0000247
Greenfield, B. L., & Venner, K. L. (2012). Review of substance use disorder treatment research in Indian country: Future directions to strive toward health equity. American Journal of Drug and Alcohol Abuse, 38(5), 483–492. doi:10.3109/00952990.2012.702170
Marsh, T. N., Coholic, D., Cote-Meek, S., & Najavits, L. M. (2015). Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduction Journal, 12(1), 14. doi:10.1186/s12954-015-0046-1
Nelson, S. E., & Wilson, K. (2017). The mental health of Indigenous peoples in Canada: A critical review of research. Soc Sci Med 176, 93–112. doi:10.1016/j.socscimed.2017.01.021
Noronha, N., Avarino, A., Balakumar, S., Toy, K., Smith, S., Wekerle, C., … Lokker, C. (2022). Mental health mobile applications developed for Indigenous communities in Canada: A scoping review. Canadian Journal of Community Mental Health, 41(1), 102–106. doi:10.7870/cjcmh-2022-004
Owais, S., Tsai, Z., Hill, T., Ospina, M. B., Wright, A. L., & Van Lieshout, R. J. (2022). Systematic review and meta-analysis: First Nations, Inuit, and Métis youth mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 16(10), 1227–1250. doi:10.1016/j.jaac.2022.03.029
Stanley, L. R., Swaim, R. C., Kaholokula, J. K., Kelly, K. J., Belcourt, A., & Allen, J. (2020). The imperative for research to promote health equity in Indigenous communities. Prevention Science, 21, 13–21. doi:10.1007/s11121-017-0850-9
Walker, J., Harris, S., Thomas, J., Phillips, M. M., & Stones, A. (2018). A national legacy framework for comprehensive and sustainable access to mental health services for Indigenous children and youth mental health in Canada. Canadian Journal of Native Studies, 38(2), 145–164.
Walters, K. L., Johnson-Jennings, M., Stroud, S., Rasmus, S., Charles, B., John, S., … Boulafentis, J. (2020). Growing from our roots: Strategies for developing culturally grounded health promotion interventions in American Indian, Alaska Native, and Native Hawaiian Communities. Prevention Science, 21, 54–64. doi:10.1007/s11121-018-0952-z
Gabriel Barrington-Moss, RN, MN, is an assistant professor in the Faculty of Nursing at MacEwan University in Edmonton.
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