CMAJ: “All my relations”: experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and well-being

May 22, 2018


BACKGROUND: Mental health services in urban settings generally have not been adapted to serve the needs of Indigenous patients. We explored how patients’ encounters with Indigenous Elders affected their overall mental health and well-being to identify therapeutic mechanisms underlying improvement.

METHODS: We conducted qualitative interviews of participants enrolled in a 6-month prospective mixed-methods evaluation of a program for mental health and well-being that featured the inclusion of Elders in the direct care of Indigenous patients in an inner city primary care clinic. Individual semistructured interviews were conducted to explore patients’ experiences and perceptions of their participation in the Elders program.

RESULTS: We included 37 participants from at least 20 different First Nations. All but 1 participant described substantial benefits from their encounters with Elders, and none reported being negatively affected. Five overarching themes were identified: experiencing healing after prolonged periods of seeking and desperation; strengthening cultural identity and belonging; developing trust and opening up; coping with losses; and engaging in ceremony and spiritual dimensions of care as a resource for hope.

INTERPRETATION: Our evaluation illustrates that the Elders program was perceived by participants to have a broad range of positive impacts on their care and well-being. Although this study was based on experiences at a single urban clinic, these findings support the Truth and Reconciliation Commission of Canada’s calls to action regarding the inclusion of Elders as a strategy to improve care of Indigenous patients in Canadian health care systems.

Mental health disparities between Indigenous and non-Indigenous people in Canada are related to underlying economic, social and political inequities that are legacies of colonization and the oppression of Indigenous cultures — now recognized as “cultural genocide” by the Truth and Reconciliation Commission of Canada.16 Therefore, disproportionate rates of mental illness and suicidality must be understood in context, not as intrinsic predispositions of Indigenous people but instead as reflecting persistent inequities.2,710 This is evident for many Indigenous people living in inner cities where the effects of poverty, racism, and other layers of discrimination and marginalization on mental health are impossible to overlook.8,9,11,12

In general, mental health services in urban settings have not been adapted to serve the needs of Indigenous patients, and this is reflected in the comparatively low rates of voluntary utilization, 13,14and much higher rates of acute admissions to hospital for suicidality and other mental health crises.15 Qualitative studies point to numerous reasons why Indigenous people express reluctance to engage with mainstream health care services: including racism, “being treated as a second-class citizen,” and lack of Indigenous staff and cultural practices.8,1620 Ethnographic data suggest that Indigenous people living in the inner city may seek out recognized Elders as informal sources of mental health care in lieu of mainstream services.12

There is widespread agreement that First Nations, Inuit and Métis Elders can play a crucial role in the mental health of Indigenous Peoples.1,5,13 Elders are recognized by their communities for possessing common qualities that are highly valued — leadership, accumulated wisdom, compassion, community devotion and dedication to personal healing.5,21,22 The designation of Elder is achieved by “those who have shown wisdom and leadership in cultural, historical, and spiritual matters within their communities, and might not necessarily be old. Elders represent an essential connection with the past; they are keepers of the community knowledge and supporters of its collective spirit.”13 Encounters with Elders can provide opportunities for patients to assert or reclaim cultural identity as part of their mental health treatment and reverse the cultural marginalization many Indigenous people have experienced in urban health care settings, such as emergency departments and hospital outpatient programs.13,14 One of the Truth and Reconciliation Commission of Canada’s “calls to action” is the inclusion of Elders in the treatment of Indigenous patients in Canadian health care systems.1

However, Elders have not been formally included or recognized as legitimate care providers within Canadian health care systems, and there have been no previous studies exploring the implementation and impact of an intervention that formally includes Elders in the provision of mental health care for Indigenous patients. Previous research found that involving Elders in a community mental health promotion strategy for teens resulted in a reduction in suicides.23 Involving Elders in patient care has also been shown to substantially decrease rates of domestic violence, 24 and to improve understanding and trust between Indigenous and non-Indigenous staff and patients.25

Our study is part of a larger investigation examining the impact of an Indigenous Elders program on the mental health and well-being of Indigenous patients in an inner city primary care setting. Quantitative results, which have been reported elsewhere,26 showed clinically and statistically significant reductions in depressive symptoms and suicidality. The goal of this study is to explore how encounters with Elders affected patients’ overall mental health and well-being to identify the therapeutic mechanisms underlying improvement.

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