How we can support Indigenous Peoples’ wellness
In honour of Indigenous History Month and National Indigenous Peoples Day, I wanted to talk about how we can support Indigenous Peoples’ wellness as healthcare professionals, and the importance of cultural competency.
These dates aim to celebrate the culture, experiences and contributions of First Nations, Inuit and Métis peoples and learn more about their history. In this sense, it’s important to understand that history is not in the past. History is ongoing. This means that trauma, for historically marginalized communities, is not in the past, either. Last month, the world was horrified to discover the remains of 215 Indigenous children in the grounds of Kamloops Residential School, in British Columbia. Although an event of such magnitude is always shocking, this was not entirely unexpected, nor an exception. This is part of Canada’s cultural genocide against Indigenous communities. We must learn it and reckon with it to understand how it has affected the autonomy, agency, and health of these communities.
When we talk about doing better towards Indigenous peoples, we need to talk about concrete ways we can facilitate their access to wellness resources that are culturally appropriate and decolonized. Mental health professionals are one type of those resources, which means that we have to work on ourselves and how we practise.
The Indigenous concept of wellness
Although there are differences in the Indigenous concepts of wellness through the different communities, families, and individuals, one thing they have in common is their holistic approach. The philosophy of the Circle of Life (1) represents the continuum of life and, contained within it, the four aspects of human nature: physical, mental, emotional, and spiritual. From a traditional Indigenous perspective, wellness is the balance of these four components, all of them equally important and necessary for an individual to be healthy. Likewise, the circle recognizes all of the aspects of a person’s existence as a whole, not in isolation, such as their connection to society, their land, and their ancestors.
There isn’t an ideal model of the Circle of Life that everyone should follow, but rather, it’s different for each of us and forever changing. It is ideal as it already is within us, guiding us to find the balance in our own lives.
Social determinants of health
The notion that health is influenced by many factors, some of which are outside our individual control, is a fact. When those factors are not related to our genetics or personal behaviours, but to the society we were born into, grow, work, and live within, we’re talking about social determinants of health (SDH).
Some examples of social determinants of health are: income, social protection, education, unemployment and job insecurity, working conditions, food insecurity, housing, basic amenities and environment, early childhood development, social inclusion or exclusion, structural conflict, access to affordable health services of decent quality, gender, race, sexual orientation, and disability (1)(2).
All of us are affected by SDH to some degree, in positive or negative ways, regardless of our personal choices. Historically marginalized groups, though, often have to contend with discrimination, racism, and intergenerational trauma in their daily lives, which play a big part as SDH. In Canada, Indigenous people face health inequities that are a direct result of SDH and, as a consequence, they generally have a lower health status than non-Indigenous Canadians (1).
There are two key SDH that health care providers should be aware of and understand in order to be able to offer culturally sensitive care for Indigenous peoples: the loss of socioeconomic status due to colonialism, and the residential school system (3). These intersect with other impacts of colonialism, such as trauma, access to basic services, and structural injustices.
Cultural competency, our duty to Indigenous peoples
Besides material barriers to accessing health care services, another issue standing in the way of Indigenous wellness is a lack of trust in a system that has historically alienated them at best and harmed them at worst. This is where cultural competency comes into play.
In a broad sense, cultural competency is “the ability to understand, appreciate and interact with people from cultures or belief systems different from one’s own” (4), and it’s a core competence in the psychology field. When framed like that, it sounds vague. If we look at a more comprehensive definition, cultural competency isn’t just about understanding and appreciating, but it’s actually “a set of behaviours, attitudes, and policies that come together in a system, agency, or among professionals which enables that system, agency, or those professionals to work effectively in cross-cultural situations” (1). It’s not enough for health care professionals to be aware that someone is different from us and respect it. It is a process that demands ongoing self-reflection and action in equal measure, by integrating culturally competent practices into our services.
Cultural competency sits at the heart of a continuum between cultural destructiveness and cultural humility, where cultural competency can be a step towards fostering cultural safety: recognizing our own learned concepts of culture into our relationships and the existence of unequal power relations, and consistently challenging them. In addition, when we’re culturally humble, we acknowledge ourselves as learners of other people’s experiences, and are able to maintain processes and relationships that are based on mutual trust and respect (1).
Supporting Indigenous peoples’ wellness
In terms of what makes treatments, practices, professionals, and protocols culturally competent, research is scarce and still ongoing. However, a relevant line of research that has been in study since the 1960s is known as “cultural adaptations” (4). What this means, in basic terms, is taking evidence-based treatments and modifying them for different groups, by involving members from these groups in the adaptation process. Research has shown that these adaptations can be effective, although, as with everything, they might not be for everyone.
Regardless of the treatment, there are other things we can do as health care professionals when offering our services to Indigenous peoples. The online booklet compiled by AHS (1) offers a guideline of 10 tips to keep in mind:
- People first – personal relationships are very important; your professional function comes second. It is helpful to establish rapport and trust as respectful human beings before entering into a professional relationship. Even a few friendly sentences before beginning the clinical interaction can help. Be genuine in your approach.
- Greet and shake hands – a personal greeting and handshake is highly appreciated by most Indigenous people as a sign of respect and acceptance. Shaking hands is also a way to say thank you. Many Indigenous people have a soft handshake so as not to appear confrontational.
- Recognize the diversity of Indigenous people – do not make assumptions. Not all Indigenous people have the same beliefs, customs or traditions. Ask individuals for their preferences; asking is always better than assuming.
- Apologize if you are rushed – hurrying is considered disrespectful; apologizing can help. Explaining that you are short for time, but will be able to spend more time later can help.
- Be sensitive to eye contact – direct eye contact may be viewed by some Indigenous people as disrespectful or insulting. Some Elders have also indicated that an aversion to eye contact is a direct result of attending residential schools, as children in these schools were afraid of making direct eye contact with school staff. Take your cue on this from the patient.
- Listen carefully and non-judgmentally – allow Indigenous people time to explain their situation and tell their story. Consider how past experiences of discrimination or abuse within institutions may affect the patient’s current experience and behaviour.
- Explain what you are doing and why – assist the Indigenous person to understand what is happening rather than treating or providing care without any explanations.
- Ask permission before touching – this demonstrates respect for the individual and takes into consideration possible sensitivities or past negative experiences.
- Appreciate the importance of extended families – extended family and friends provide very important supports for an ill Indigenous person. If there are many visitors, try to accommodate them as you are able, or find a place for them. Ask the family to identify one person to be the spokesperson and contact for the family.
- A holistic health approach – traditional Indigenous health perspectives are often holistic: encompassing physical, mental, emotional and spiritual well-being. Facilitate requests for spiritual and cultural practices that promote health and healing when appropriate.
Providing culturally safe care can encourage historically marginalized people to access healthcare services earlier, return for check-ups, and follow treatment plans. This means they’ll be less likely to develop critical situations and more likely to see better health outcomes. At the same time, making people feel at ease and empowered during the process can result in them being more inclined to share their concerns and preferences, as well as relevant information with their care providers.
Culturally safe care is a right, and it’s our duty as health care professionals to provide it. I invite you to make it your mission to be as culturally safe in your practice as you’re able to!
(1) Alberta Health Services. Indigenous Peoples and Communities in Alberta. https://together4health.albertahealthservices.ca/14632/widgets/56737/documents/34245
(2) World Health Organization. Social Determinants of Health / Health Topics. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
(3) Paul J. Kim. Health Equity. Jul 2019. 378-381.http://doi.org/10.1089/heq.2019.0041
(4) DeAngelis, T. (2015, March). In search of cultural competence. Monitor on Psychology, 46(3). http://www.apa.org/monitor/2015/03/cultural-competence
I grew up speaking Spanish. English is my second language. When I communicate in English, I make mistakes. I've chosen to let the writing on my blog reflect the kind of mistakes I make when speaking, so that you have an idea of what it might feel like to talk to me. I trust the message is still clear but, if it's not, please don't hesitate to ask me for clarification.
The information provided on my blog is a mix of my personal thoughts, professional approach, and articles related to mental health. The purpose of sharing all of this is to communicate the models at the core of my practice, as well as to provide education. I hope this will help to minimize some of the power imbalances related to my profession. The articles on this blog should not be considered as professional advice for any one person or group of people. If you have any questions about the appropriateness of this content for you, please contact a qualified mental health professional.