Indigenous Perspectives on Mental Health Service Delivery: What needs to change

During the process of researching topics for this blog I have tried to think of stories and experiences from my field placement in mental health that I would be able to incorporate into my entries.  As I poured over the different experiences and situations that I have encountered in my placement I realized that I have yet to work with or even see any older Aboriginal patients.  The more I thought about this, the more I began to question why this is.    Based on my previous knowledge of issues affecting Aboriginal people I definitely know that this has nothing to do with the fact that Aboriginals don’t experience mental illness or mental health issues, in fact I know this is to the contrary.  According to Stewart (2008) the Aboriginal community experiences a disporportianetly high number of mental health issues compared to the rest of Canada, but at the same time mental health services are under utilized by Aboriginal people.  So why is this? Although there are a number of complex issues that are beyond the scope of a single blog entry, there are a number of key issues that are present and have a direct relationship to our roles as social workers.

One of the first possible explanations that could explain the under utilization of mental health services by Aboriginal people is the underlying worldviews that are held by Aboriginal people, namely that one’s health is holistic and that health also refers to a person entire being.  This notion means that health is looked at as being a balance on one’s physical, mental, emotional and spiritual being. (Smye, Mussell, 2001)  The views held by Aboriginal are in conflict to the traditional biomedical approach to illness that is very Eurocentric in nature. (Kafele, 2004) The divergence in these two ways of thinking becomes very apparent when we look at a counselling approach to mental illness.  Stewart (2008) states that counselling in mental health has not been successful for many indigenous people because mental health counsellors often lack an understanding of Indigenous people’s concepts, including their ideas of health and their worldviews.  In fact a 1977 study cited by Stewart (2008) found that native clients do not value or utilize counselling services that are not adapted to a first nations helping model.  If we look at Aboriginal elders in particular, it seems more likely that they would not readily seek out counselling for mental health issues because often times, they themselves would be the people in the community that others would go to for advice because they may be seen as being wise or knowledgeable about traditional healing ways and mental illness.

As Stewart (2008) explored the issue of what Aboriginals people consider to be important in the process of mental health and healing she discovered four main themes that were expressed by Aboriginal people as being important to them.

Community

Aboriginal people identified community as being a central component of mental health and healing.  Community in this sense was identified as a collective or social grouping with others to which some link to indigenous culture exists. (Stewart, 2008)

Cultural Identity

Cultural identity was also shown to be an important component to maintaining mental health.  Incorporating traditional ceremonies and spiritual acts such as dance and different traditional ceremonies was shown to be something that Aboriginal people would like to see more of in mental health counselling. (Stewart, 2008)

Interdependence

The concept of interdependence was also identified as being extremely important to Aboriginal people within the therapeutic relationship.  This was identified as being important because in day to day life Aboriginal people typically rely on one another in all of their daily relationships.  Therefore this was seen as being integral to the therapeutic relationship between an Aboriginal client and their counsellor to promote mental health and healing. (Stewart, 2008)

Holistic Approach

In Stewart’s study she found that Aboriginal people considered a holistic approach to healing to be of the utmost importance.  Stewart (2008) identified that Aboriginal people want a holistic approach to be regarded as a mainstream way of looking at mental health services, rather than just being an alternative.  Some examples of what a holistic approach to counselling could include taking clients into nature or back into their community or integrating prayer or ceremonies such as smudging.

These themes were the four main points that were raised by Aboriginal people as being important to them to improve current mental health services.  Unfortunately we still have a long way to go to incorporate these approaches into the mental health system, which is still very illness based and Eurocentric.   The lack of culturally appropriate services has meant that a very few Aboriginal people seek out mental health services and when they do they often lack confidence in the system.  One of the main things that I believe that we can do as future social workers is become an ally to the Aboriginal community and advocate that these approaches to mental health become more actively utilized when we work with Aboriginal clients.  Although I know that I won’t be able to claim any expertise in this area I believe that it will be important to continue to educate myself in different Aboriginal approaches to healing and try to work with Aboriginal people to incorporate these approaches into my practice whenever possible.

Kendall

References-

Kafele, K. (2004) Racial Discrimination and Mental Health: Racialized and Aboriginal Communities. Race Policy Dialogue Conference Paper. Ontario Human Rights Commission.

Smye, V., Mussell, B. (2001) Aboriginal Mental Health: What works best: A Discussion Paper. Mental Health Evaluation & Community Consultation Unit 1-40

Stewart, S. (2008) Promoting Indigenous mental health: Cultural perspectives on healing from Native Counsellors in Canada. International Journal of Health Promotion & Education 46(2) 12-19

Advocating for the Rights of Indigenous Seniors

Recently research studies have determined that Indigenous communities across North America, New Zeland and Austraila all share many of the same factors which contribute to health disparities, they include; location, poverty and communication barriers, and end in the same result…unequal access to  health care. (Marrone, 2007) You need not look that far afield in order to see this issue, as example of this has recently occurred to Indigenous seniors in Manitoba.  It is for these reasons that it is important to ensure that there is strong advocacy in place for Indigenous seniors.

             

One major issue currently affecting ageing Indigenous populations living in northern communities in Manitoba is the lack of services and health care supports. CBC News aired a report about an issue that has occurred in Oxford House reporting that 28 seniors were been forced to live in a high school because the roof of their personal care home had caved in. “The high school has no bathing tubs or areas to cook meals, let alone care for vulnerable people at risk of infection, bed sores and pneumonia”, Dr. Walter Hoeppner stated in an interview.  He goes on to say that Health Canada has refused to airlift the seniors becuase they are not sick enough. Health Canada said it is working on a plan with the Department of Indian and Northern Affairs and Manitoba's Burntwood Health Authority to have the seniors moved and neither agency would say when that might happen. (CBC News Canada, 2011)

Currently the federal government is responsible for home care service case management, nursing, and homemaking these programs are not meeting all of the home care needs of First Nations Communities. (Prince & Kelly, 2010) However, according to Health Canada 2008, the federal government holds that there is no constitutional obligation or treaty that requires the Canadian government to offer programs or services to Aboriginal peoples (including First Nations living on reserves and Inuit living in settlements). In contrast, Aboriginal peoples link federal health programs to treaty obligation and the broader trustee role of the federal government. (Prince & Kelley, 2010)

As a social work student, throughout my practicum at a personal care home, I have learned how to provide: resources, services and how to advocate for seniors and their families. I feel the most important skill I have developed is advocacy.  Advocacy being, "The act of directly representing a course of action on behalf on one or more individuals, groups, or communities, with the goal of securing or retaining social justice (Mickelson, 1995 as stated in Zastrow and Kirst-Ashman, 1997).

Throughout advocating for residents at my practicum placement I have realized that I would like to continue on working with the ageing population. I am interested in doing work with the ageing Indigenous population who are living in Winnipeg who have come from Northern Communities. I believe that this is a useful role as there has been an increase in the Indigenous senior population. One study indicates that;

Within the Aboriginal population, what is changing is the relative size of the elderly population where Older Aboriginal Peoples were among the fastest growing age cohorts between 2001 and 2006 and their relative size in relation to the rest of the Aboriginal population is likely to continue to grow given the growth in age cohorts that are now 55 to 64 and 45 to 54. Geographically, to a large extent these demographic trends are occurring across Canada, and the growing urban nature of the Aboriginal population in general and the Older Aboriginal Peoples will need to be taken into account in the coming decades. (Rosenberg et. al, 2008, p.3)

          

Some of the research based solutions that can address the need for palliative care research and programs in First Nations communities are:    

1) Support Community health care workers who have been trained in palliative care to develop culturally appropriate educational resources and educate other community members about palliative care.   

2)  Revision of the existing Home and Community Care Program to include palliative care as an essential element of the program and to increase funding levels to meet the increase demand for care and higher level care needs.

3) The promotion of innovative models of integration, consultation, and collaboration that will support primary health care providers in First Nations Communities. (Prince & Kelly, 2010)

In a study conducted by Health Canada in 2008, it was determined that at the present time advocacy is needed in order to stop the inconsistencies in the provision and delivery of home care services, and substantial gaps that exit due to jurisdictional issues and funding efficiencies. (as stated in Marrone, 2007)

As a future social worker and as an Indigenous person I need to continue on educating myself about the needs of Indigenous seniors so that I can be a better support and represent them. Advocacy for Indigenous seniors is needed and their voices need to be heard.           

In Winnipeg, there are services and programs for the ageing population that Indigenous people can have access to in Winnipeg. The Indigenous population continually face many challenges that make it difficult for them to receive services and programs such as discrimination, language barriers, transportation issues and isolation. Programs have been developed and services are available in order to help full fill needs to the senior population needs. Indigenous seniors are eligible for these programs that can benefit and provide services to them. Some programs and services are:

Aboriginal Centre of Winnipeg: a gathering place for people and a centre to foster new ideas in education, economic development, social service delivery and training.

Aboriginal Senior Resource Centre: providing resources for aboriginal seniors.

Alzheimer Society of Manitoba: seeks to achieve its mission through community awareness; individual, family and professional education; support programs; and research funding.

Community Seniors Resource Councils (Support Services for Seniors): support older adults as individuals or in groups.

Crisis stabilization units - Salvation Army: support seniors in a crisis.

Housing: Seniors Resource Network: housing services.

Manitoba Home Care Program: Home Care is provided to Manitobans of all ages based on assessed need and taking into account other resources available to the individual including families, community resources and other programs.

Respite (In-home) Services: provide support to caregivers and individuals in order to foster independence and participation in the community.

Seniors & Healthy Aging Secretariat Winnipeg: providing support to seniors.

Supportive Housing: supportive housing for seniors.

-Arlene-

"Keeper of the Fire"

            Warrior, what do you think of when you read that word? Do you think of a man? a man with big muscles, maybe armor or a sword?  or young and healthy? These are probably the images that come to mind.

            Would you ever think a woman could be a warrior? What about older women? That may not be what first comes to your mind when you think of a “warrior” but as the film “keepers of the fire” shows women, even older women, can be warriors too.

            The film Keepers of the Fire tells the story of Indigenous Women across Canada who have stood up and fought for their rights and the rights of their people… and won.

At the very opening of this film the narrator states:

“The old ones have a proverb and it goes something like this. ‘No people is broken until the hearts of its women are on the ground. Only then are they broken, only then will they die’.

For 500 years our mothers and grandmothers have kept the fires burning in the hearts and minds of our people. They were warrior women, storytellers, dreamer, healers, fighters and through them we survived. It is our time now; the fires are ours to keep. And I find myself wondering what kind of warriors are we?”

This film depicts different battles that Indigenous women have fought over the years. The Oka crisis, the battle for Lyle Island and Bill C-31 are all examples of times where women were required to make a choice, to stand up and fight or to give in and give up. The decision to stand up and fight shows the strength and courage that Indigenous women have and is a great source encouragement to future generations.

One woman from Oka named Debbie explains that Mohawk women have always been a “force to be reckoned with” and the clan mothers chose the chiefs of the long houses. In Mohawk society women were also often the heads of the households. Debbie also explained that in Mohawk law the land was “entrusted” to the women and they have a “sacred responsibility to protect it”. This sacred duty to the land, as she describes, was also a responsibility seven generations into the future, to protect the land so there is something left for those who are still yet to come. The film explains that when the crisis happened in Oka the women were the ones who brought everyone together to fight and the women also went to the front lines. There were plans for a golf course to be built where a acred pine forest was and where many of their ancestors were buried. Due to the conflict the Canadian military was called in to address the situation. The women who stood up in Oka had tear gas and bullets shot at them and they were barricaded into their community by military force yet they did not give in. They protected their beloved pine forest from being turned into a golf course and brought Indigenous issues to the forefront.

One woman stated

“Something just went through me that gave me the strength and courage to not run away”

and another:

“We got to a point that we were more mad than we were afraid”.

Another example of strong women in this film was the women who fought for Lyle Island. Loggers were threatening the life of the beautiful forest. Haida people came from across Canada to stand together and create a barricade to protect the land. The Elders were the ones who were the first to stand at the Barricade. Despite the desire of the young people to protect their Elders from being arrested the Elders went anyway. Both men and women sat at the barricade and took a stand for what they believed in. They were eventually arrested but in the end the determination and courage of this group won the battle for Lyle Island which is now a protected area.

On the other side of Canada women rallied together to fight for their rights that had been taken from them. Their status rights as Indigenous peoples had been stripped from them because they had been married to white men. When these women moved back to their communities they lived in dire conditions because they were no longer status. Aboriginal women’s did not have rights and were treated as such. However some women decided that enough was enough and they took a stand. They occupied their band office and as the film says “brought the government to its knees” bringing in bill C-31. This bill restored the status rights of women who had unjustly lost them. This was a great victory for Indigenous women and should inspire future generations to continue the fight.

            As a social work student I find that although we talk about the strength based approach to helping the nature of our profession leads us to focus on many of the negative circumstances facing the people groups we serve. With the Indigenous population I believe this is also true. Often times we become immersed in the barriers faced by Indigenous people we forget to remind ourselves of the strengths of this population. There many strengths in Indigenous communities and those strengths are also within each individual. In the literature especially there is a problem focus. This maybe necessary at times because in order to make changes we have to determine what problems exists. As an non-Indigenous person who desires to be and is learning to be an ally, I wonder what would be different if we heard more stories like those of the women in this film. What if we knew more about the women who support these communities and the warriors that they are; would we think differently? What if we as women knew more about each other and felt connected to each other’s stories. Maybe we as helper could find a way to support these women to bring about further changes, as great or even greater than the victories highlighted in this particular film.

I love this film and want to share it with you because it tells the stories of strong Indigenous women who’s stories I may never have heard otherwise; These stories of strong women inspire me to continue to fight and stand up for what is right. These stories remind me that change can happen and that there is great strength within Indigenous peoples especially in their women. In closing I would like to recognize that there are many more stories of strong Indigenous women that remain untold or hidden. I wonder what more we could learn if we heard more of their stories.

I am challenged by the courage demonstrated by these women and now I find myself wondering what kind of warrior am I?

-Meagan

***this film is available in the U of M library at the circulation desk.

Hospice and Palliative Care: Barriers to Accessibility for Aging Aboriginal Peoples

When I began my final practicum placement on the Palliative Care Unit I did not have a very broad understanding of cultural awareness and sensitivity to issues surrounding end-of-life care. In complete honesty, I did not have a very good idea of what Palliative Care in general meant. Over the past 8 months on the unit I have come to learn the difference between Palliative Care and the dominant curative bio-medical based model of care. Instead of taking the curative approach to care, Palliative Care places a heavy emphasis on the psycho/social/spiritual needs of the individual while maintaining adequate symptom management through one’s end of life care (Williams, Crooks, Whitfield, Kelley, Richards, DeMiglio, and Dykeman, 2010).

The emphasis on psycho/social/spiritual care has marginalized Hospice and Palliative Care within the larger medical model based health care system (Williams et al, 2010). Within the medical model hierarchy, the bio-curative medical ideology is dominant. However in palliative care a hierarchy also exists. Hospice Palliative Care’s emphasis on western euro-centric approaches to psycho/social/spiritual care is the dominant ideology, and Aboriginal focused Hospice and Palliative Care is delegated to the lowest rung within this sub-category of care. How does this hierarchy manifest itself in the care that older Aboriginal people receive during their end stages of life?

Kelly and Minty (2007) compiled a report focused on the end-of-life challenges that Aboriginal peoples in rural communities are presented with, which include: little to no access to medical procedures; high turnover rates of doctors and nurses; lack of inpatient facilities; and difficulty accessing necessary medications. As a result of such inadequate supplies, knowledge, and care, older Aboriginal people living in the end stages of chronic illness have to leave their home communities to receive the necessary medical treatments that only urban centres can provide. Having to move away from one’s home community, into an institution, during the end stages of an illness can be extremely difficult and for an older person. Such a transition can lead to isolation, loneliness, and depression.

In Castleden, Crooks, Morgan, Schuurman, and Hanlon (2009) article, which focused on an intertribal discussion between three rural Aboriginal communities, it was discovered that major knowledge disparities existed within Hospice Palliative Care. The key informants felt that there was a lack of both Aboriginal cultural sensitivity and necessary cultural resources. Cultural services and accommodations that would create an atmosphere of safety and inclusion for an older Aboriginal person on the unit were identified as: including family and community members in decisions regarding the person’s treatment; providing interpreters who speak the same language as the person; and helping the older person to build a relationship with the doctor over a period of time.

As a social workers I think it is very important to be aware of the tumultuous relationship that has existed between Aboriginal peoples and the health care system. Kelly and Minty (2007) noted that older generation of Aboriginal people who are now entering the system have a great mistrust of the health care system. A history of mistrust and cultural trauma has put up many barriers to collaboration between patients and doctors. The older Aboriginal patient and the doctor are coming from two different perspectives with expectations and assumptions as to how communication should occur and how decisions for their care ought to be made. It is very difficult to overcome such barriers when the older adult is in a hospital bed, removed from their community, family, and culture. Castleden et al (2009) discovered that many older Aboriginal people, in their end-of-life planning, desire to re-connect with traditional ways of healing and culturally appropriate practices particular to this stage in their life. As a social worker on a palliative unit, part of being culturally aware would include linking my patients with community resources that would be able to meet their cultural needs. Part of my responsibility would also include inviting outside Aboriginal agencies to come and give presentations to the staff about Aboriginal perspectives on dying, and rituals surrounding end-of-life care.

When I first began my placement I had a discussion with a nurse who recounted their experience of caring for an older Aboriginal patient in their end stages of life. The nurse talked about the amount of people in the room, and how intimidating it was. As the nurse was discussing this with me I began to realize that the reason the situation was so intimidating was because of a lack of knowledge and understanding of the cultural relevance of what was happening. The nurse felt outnumbered, and felt that everybody was scrutinizing their every move. Upon reflection of the story I think that this individual would have greatly benefited from cultural sensitivity training. Had this person been educated about Aboriginal community rituals at end-of-life care they would have seen a completely different picture. Instead of commenting on how many people were in the room watching their every move, they may have actually felt honoured and humbled to be part of this community’s experience with the dying person.

In closing, I think that Aboriginal awareness training in the health care system would be the first step in bridging the knowledge gap between Aboriginal culture and the Western approach to health care. Yes, I realize this is a massive undertaking, and one that would not happen instantly, however I think it would be a step in the right direction. Thanks for reading.

-Michelle Kehler

Williams, A., Crooks, V., Whitfield, K., Kelley, M., Richards, J., DeMiglio, L., and Dykeman,
            S. (2010). Tracking the evolution of hospice palliative care in Canada: A comparative
            case study analysis of seven provinces. BMC Health Services Research, 10(147).

Kelly, L., Minty, A. (2007). End-of-life issues for Aboriginal patients a literature review.
            Canadian Family Physician Journal, 53 1459-1456.

Castleden, H., Crooks, V., Morgan, V., Schuurman, N., & Hanlon, N. (2009). Dialogues on
            Aboriginal-Focused Hospice Palliative Care in Rural and Remote British Columbia,
            Canada. Nanaimo, BC: Inter Tribal Health Authority