Researching Prescription Drug Misuse among First Nations in Canada: Starting from a Health Promotion Framework

Abstract

The intentional misuse of psychotropic drugs is recognized as a significant public health concern in Canada, although there is a lack of empirical research detailing this. Even less research has been documented on the misuse of prescription drugs among First Nations in Canada. In the past, Western biomedical and individual-based approaches to researching Indigenous health have been applied, whereas First Nations' understandings of health are founded on a holistic view of wellbeing. Recognition of this disjuncture, alongside the protective influence of First Nations traditional culture, is foundational to establishing an empirical understanding of and comprehensive response to prescription drug misuse. We propose health promotion as a framework from which to begin to explore this. Our work with a health promotion framework has conveyed its potential to support the consideration of Western and Indigenous worldviews together in an 'ethical space', with illustrations provided. Health promotion also allots for the consideration of Canada's colonial history of knowledge production in public health and supports First Nations' self-determination. Based on this, we recommend three immediate ways in which a health promotion framework can advance research on prescription drug misuse among First Nations in Canada.

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Substance Abuse: Research and Treatment
COMMENTARY
Substance Abuse: Research and Treatment 2012:6 23
Researching Prescription Drug Misuse among First Nations
in Canada: Starting from a Health Promotion Framework
Colleen Anne Dell1, Gary Roberts2, Jennifer Kilty3, Kelli Taylor4, Mitch Daschuk5, Carol Hopkins6
and Debra Dell7
1University of Saskatchewan, Department of Sociology and School of Public Health, Saskatoon, Saskatchewan, Canada.
2Gary Roberts Consulting, 3University of Ottawa, Department of Criminology and the Social Science of Health, 4University
of Calgary, Faculty of Medicine, 5University of Saskatchewan, Department of Sociology, 6National Native Addictions
Partnership Foundation, 7Youth Solvent Addiction Program. Corresponding author email: colleen.dell@usask.ca
Abstract: The intentional misuse of psychotropic drugs is recognized as a signicant public health concern in Canada, although there
is a lack of empirical research detailing this. Even less research has been documented on the misuse of prescription drugs among
First Nations in Canada. In the past, Western biomedical and individual-based approaches to researching Indigenous health have been
applied, whereas First Nations’ understandings of health are founded on a holistic view of wellbeing. Recognition of this disjuncture,
alongside the protective inuence of First Nations traditional culture, is foundational to establishing an empirical understanding of and
comprehensive response to prescription drug misuse. We propose health promotion as a framework from which to begin to explore
this. Our work with a health promotion framework has conveyed its potential to support the consideration of Western and Indigenous
worldviews together in an ‘ethical space’, with illustrations provided. Health promotion also allots for the consideration of Canada’s
colonial history of knowledge production in public health and supports First Nations’ self-determination. Based on this, we recommend
three immediate ways in which a health promotion framework can advance research on prescription drug misuse among First Nations
in Canada.
Keywords: intentional prescription drug misuse, First Nations, health promotion framework, Indigenous health

Dell et al
24 Substance Abuse: Research and Treatment 2012:6
Introduction
Despite the fact that Canada’s prescription drug rates
rank among the highest in the world, current research
detailing Canadian trends in intentional psychotropic
drug misuse is lacking.1 Available data on the non-
medical use of prescription drugs and the health, social
and economic impacts among Canada’s First Nationsa
population is especially sparse. There is increasing
public attention, however, to prescription drug mis-
use as a signicant health concern.2 This dates back
to concern expressed by Canada’s Auditor General in
1997 and again in 2004 of opiate-based prescription
drug misuse in First Nations communities.3,4 The non-
medical use of prescription drugs has been linked with
the impoverished health status of First Nations across
Canada; a growing number of First Nations have asso-
ciated elevated rates with increased levels of violent
criminality, illicit prescription drug trafcking, and
suicide within their communities.5–7 For example, in
early 2012 Cat Lake First Nation in Ontario was the
latest First Nations community to declare a state of
emergency to federal and provincial ofcials due to the
widespread use of prescription drugs.8 The most recent
First Nations Regional Longitudinal Health Survey,
released in 2011, reported that addiction was the pri-
mary challenge (83%) to on-reserve community well-
ness—a greater challenge than both housing (71%) and
employment (66%).9 Despite increased public aware-
ness and media attention and select national, provin-
cial/territorial and local community action, a lack of
empirical research renders the issue poorly understood
and therefore somewhat sporadically responded to.
Research with First Nations in Canada has his-
torically been a colonizing practice, with information
overwhelmingly taken from communities with little
regard for its cultural signicance and meaning out-
side a Western worldview and without clear benet to
improving the health of First Nations. Over the course
of the past decade, Canada has taken signicant action
to address this, with attention allotted specically to
ethics in research. For example, the revised Tri-Council
Policy Statement for Research Involving First Nations,
Inuit and Métis Peoples of Canada was released in
2010.10 The statement was developed from extensive
community consultation and prior work, including the
Canadian Institutes of Health Research Guidelines for
Health Research Involving Aboriginal People and the
First Nations Information Governance Centre’s prin-
ciples of OCAPb.11,12 At the same time, Indigenous
methodology scholars, such as Smith (1999),13 Kovak
(2009),14 and Wilson (2008)15 have made major con-
tributions to increasing understanding of the decolo-
nizing potential of research. What remains fairly
unexplored, however, is what Ermine (2007;2004)
refers to as an ‘ethical space’; a space in which West-
ern and Indigenous worldviewsc and researchers can
come together.16,17 Tait (2008) argues that researchers
unfamiliar with Indigenous knowledge have moral and
ethical obligations to gain an understanding and that
this must be paramount in research with Aboriginal
communities; this “ethical space facilitates [the] devel-
opment of cross-cultural linkages that are ethically
sustainable and strive for equality of thought amongst
diverse human communities” (page 3).18
It has been our experience working with a health
promotion framework that it can be a suitable starting
point for generating an ‘ethical space’ in which Western
and Indigenous worldviews can be concurrently
considered. Essential to creating such an ‘ethical space’
is clarication of applied values, which in turn act to
dene the space and enable expanded collaboration
between varying worldviews. Health promotion is about
situating people’s health in relation to their environ-
ment, framed as a bio/psycho/socio/cultural perspective
through an Indigenous conception of the determinants
of health. At the same time, we have experienced that
this framework has the capacity to recognize the pro-
tective inuence of First Nations traditional culture and
First Nations self-determination, while also realizing
Canada’s colonial history of knowledge production in
the health eld. The prescription drug misuse research
eld is apt for its application, especially consider-
ing the limited amount of research undertaken to date
and the current environment of heightened awareness
of prescription drug misuse. We recommend three
aThe Constitution Act of 1982 identies three Aboriginal groups in Canada:
Indians (First Nations), Inuit and Métis. First Nations generally applies to both
Status Indians (recognized under the Indian Act by the Government of Canada
and entitled to certain rights and benets under the law), and Non-Status Indians
(not recognized under the Indian Act for whatever reason, such as status cannot
be proven or status rights have been lost). There are unique similarities and vast
differences within and among First Nations populations.
bOwnership, control, access and possession.
cThere is no one Western or Indigenous worldview, but for the sake of presenta-
tion in this paper, the commonalities within each are focused on.

Prescription drug misuse among First Nations
Substance Abuse: Research and Treatment 2012:6 25
immediate ways that a health promotion framework can
move research on prescription drug misuse among First
Nations in Canada forward and in alliance with active
initiatives such as the Canadian Centre on Substance
Abuse’s lead on a national strategy in partnership with
the Assembly of First Nations, First Nations and Inuit
Health Branch, National Native Addictions Partnership
Foundation and Non-Insured Health Benets among
others.
Aboriginal health and prescription
drug misuse
There is considerable heterogeneity among First
Nations populations, yet various commonalities con-
tribute to a state of poor overall health status. Compared
to other Canadian populations, existing data relay that
First Nations’ health status is considerably poorer.19
Adelson correlates this with “[a] history of colonialist
and paternalistic wardship, including the creation of
the reserve system; forced relocation of communities
[and] forced removal and subsequent placement of
children into institutions far away from their families
and communities; inadequate services to those living
on reserves; inherently racist attitudes towards Aborig-
inal peoples; and a continued lack of vision in terms
of the effects of these tortured relations”.20 (page 46)
Examining the pathways to prescription drug mis-
use, in comparison to the general Canadian popula-
tion, First Nations adults have a higher frequency of
chronic disease and some ailments are associated with
physical pain, such as arthritis/rheumatism, high blood
pressure, diabetes, asthma, heart disease, cataracts,
chronic bronchitis, and cancer.21 Mental health issues
(eg, emotional pain) also abound and stem from unre-
solved trauma (ie, colonization), with studies relaying
that individuals are oftentimes unable to easily distin-
guish emotional and physical pain.22,23 The determi-
nants of health for First Nations, including poverty,
loss of language, racism, and dissociation from the
land, markedly contribute to decreased overall health
levels, resulting in an average ve to seven year lower
life expectancy when compared with non-Indigenous
Canadians.24 First Nations women encounter further
health disparities stemming from gender-based deter-
minants, including increased incidents of family vio-
lence and the demands of single parenthood.25
Although there is limited research specic to First
Nations and prescription drug misuse, there has been
emerging evidence over the past two decades pointing
to a growing problem. Dating back to 1994/95, data
from the National Native Alcohol and Drug Abuse
Program (NNADAP) Treatment Activity Reporting
System suggested an increasing trend in the abuse of
narcotics and prescription drugs among First Nations
accessing treatment in Canada.26 In a review of pre-
scription drug use from this same data system in the
late 90s, Thatcher concluded that prescription drug
abuse “is increasing among First Nations and Inuit
people who are referred to NNADAP in-patient
treatment programs”.27 (page 4) Similarly, a general
review of NNADAP in the early 2000s found that
35% of social service workers i dentied problematic
prescription drug use as a frequent or constant prob-
lem in their community, and recommended that “the
issue of prescription drug abuse … be examined”.28
(page 18) More recent, the renewal of the NNADAP
and Youth Solvent Abuse Program (YSAP) treatment
system identied intentional prescription drug misuse
as an area of increasing concern and research need
in its regional needs assessments, with specic con-
cern raised in Ontario, Alberta and New Brunswick
and growing concern in Saskatchewan and Quebec
(eg, OxyContin, methadone, codeine).29 The YSAP pro-
gram has identied in its database an increasing concern
among youth admitted for treatment since 2006–07.30
And lastly, it was recognized at the 2010 Assembly
of First Nations Special Chiefs Assembly that opiate
addictions and related harms are emerging substance
misuse challenges that need to be addressed.31
Contextual issues, such as colonial history, geography
and gender must be accounted for to understand the
growing concern. To illustrate, post-traumatic stress
is a common disorder diagnosed among residential
school survivors and is frequently treated with
benzodiazepines.32 In the province of Saskatchewan,
substantial prescribing of benzodiazepines has been a
concern, although it has decreased with the introduction
of a prescribing awareness program but in place
concern has emerged about the abuse of Ritalin and
Gabapentin.33 As another example, a 2007 Saskatchewan
study found that “differences in prescription drug abuse
exist between northern and southern Saskatchewan
First Nations reserve communities. These differences
are related to factors such as prescriptive practices
and delivery of medications; geographical location
(remote versus non-remote locations, proximity to

Dell et al
26 Substance Abuse: Research and Treatment 2012:6
urban centres); and, the accessibility and availability of
illicit and licit substances. For example, physicians are
employed on a contract basis in the north and therefore,
the dispensing of medications/mood altering drugs is
not as high volume driven as it is in the south where
First Nations people access off-reserve physicians who
are paid by the number of patients they see”.34 (page 5)
Additionally, several studies across the country have
relayed that there is higher prescription rates for
Aboriginal women in comparison to other populations,
including Aboriginal men.35,36
Alongside the devastating intergenerational impacts
of colonization on the intentional misuse of prescrip-
tion drugs, it is necessary to likewise acknowledge the
protective inuence of traditional culture on the health
of First Nations in Canada. Research on the causes
and best responses to prescription drug misuse need to
better reect culturally-based understandings of well-
being.37 To date, many have argued that Indigenous
health research has largely been undertaken from an
individualized Western approach that tends to perpetu-
ate the legacy of colonialism by denying the validity of
First Nations understandings and practices of health.38
Many traditional First Nations perspectives on health,
healing and medicine are at odds with purely Western
biomedical understandings.39–41 Health is understood
by various First Nations as a state of unity and bal-
ance across the biological, psychological, social, and
spiritual aspects of one’s life—not simply the absence
of disease. A 2006 meeting on the wellbeing of First
Nations explained that “[t]he traditional ecological
knowledge of Indigenous people [focuses on] the web
of relationships between humans, animals, plants,
natural forces, spirits, and the land forms in a particu-
lar locality, as opposed to the discovery of universal
laws”.42 (page 4) In Canada, the 2011 Honouring Our
Strengths renewal framework on First Nations treat-
ment for substance abuse (NNADAP/YSAP) places
culture at its core.43 Carol Hopkins, co-Chair of the
Renewal Leadership Team, shares: “It has been our
own cultural ways that have upheld the truth of who
we are and it is that knowing from which we will draw
upon as our cultural evidence to facilitate renewal and
revitalization”.44 (no page, internet source)
Health Promotion Framework
Health promotion is a population-based, systemically
integrated approach to addressing individuals’ health,
while simultaneously accounting for individuals’
health choices. The World Health organization
denes health promotion as the process of enabling
people to increase control over the determinants of
health in order to improve their health.45 Inherent to
this approach is an understanding that health is deter-
mined in large part by structural inuences, com-
monly referred to as the determinants of health. The
underlying assumption is that “reductions in health
inequities require reductions in material and social
inequities”.46 Quite simply, “[t]he conditions in which
people grow, live, work and age have a powerful inu-
ence on health. Inequalities in these conditions lead to
inequalities in health”.47 (no page, internet source)
A long-standing criticism of health promotion is
that it does not ‘t’ for populations who do not have
access to the resources necessary to engage in health
promotion initiatives; a key challenge has been putting
health promotion theory into practice.48 As Aboriginal
ACT Now in BC notes “... despite an emphasis on health
inequalities and determinants, health promotion is in
many respects a ‘white, middle-class phenomenon’
that has [been] met with mixed results amongst ethnic,
racial, and cultural minorities and poor populations”.49
(page 7) In light of this criticism and the framework’s
foundation in Western thought, health promotion has
responded by adapting to the inclusion of culturally-
based understandings of health and their application.50–52
According to Mundel and Chapman (2010), in their
application of the health promotion framework to a
case study of an urban Aboriginal community kitchen
garden, “[h]ealth promotion’s ... holistic conceptual-
ization of health (for example, addressing the needs of
the whole person), its preventative focus and its accep-
tance of the need to change social and economic con-
ditions in order to improve health suggest that it holds
greater potential for promoting Aboriginal health than
relying solely on biomedicine”.53 (page 167) This is
also evident in the emergent attention to Indigenous-
specic determinants of health in Canada and interna-
tionally, including historical trauma, language and land
displacement, and poor standards of living.54,55
An ‘ethical’ space
The work of authors of this paper (Dell, Hopkins &
Dell) within the health promotion framework has
appropriately enabled an ‘ethical space’ to transpire for
our team members, that is, a space in which we could

Prescription drug misuse among First Nations
Substance Abuse: Research and Treatment 2012:6 27
address working with both Western and Indigenous
understandings of health. For example, our recent
project titled From benzos to berries: An examination
of the inuence of culture in treatment offered at an
Aboriginal youth solvent abuse treatment centre, con-
sidered the implications of taking into account culture
within psychiatry’s individualized approach to treating
mental disorders amongst youth solvent abusers. Our
team’s initiation from within a health promotion frame-
work enabled a space for divergent perspectives to be
considered. For example, we contemplated in our work
how Indigenous youths’ understandings of connection
to self, community, and political context, alongside the
determinants of health, can be accounted for together
to understand treatment. Based on our experience with
the framework, we concluded that “a health promo-
tion perspective may be a valuable beginning point for
attaining…understanding, as it situates psychiatry’s
approach to treating mental disorders within the etiol-
ogy for Aboriginal Peoples”.56 (page 80)
Accounting for the protective inuence of First
Nations traditional culture
Much of the emerging health promotion literature
describes the importance of acknowledging, under-
standing, reecting upon, and incorporating varying
cultural constructions of health.57–61 As such, a health
promotion framework provides an opening for
consideration of the protective and healing inuences
of First Nations cultural understandings, teachings and
practices of healing and medicine. In order to connect
with Aboriginal peoples in Canada, health promotion
efforts must include an understanding of the values
which underpin the various benets of community-
based Indigenous healing traditions, rituals, ceremonies,
medicines and practices that positively impact the health
of First Nations. Due to the historical over-emphasis on
biomedical explanations of health in Western society,
however, empirical documentation of the inherent
strengths and abilities of First Nations’ own health and
healing are sparse.62,63 In our From benzos to berries
project, we explored an Elders’ simultaneous reliance on
both an Indigenous (traditional medicine) and Western
(behaviour modication) approach to treatment and
healing, while at the same time respecting that some
traditional cultural knowledge is not for documentation
(eg, ceremonial process, ceremonial songs, and
medicines). The health promotion framework enabled
us to explore a bridging of the gap in understanding
between Western psychiatric and Aboriginal
understanding and practices, and thereby potentially
positively impact client outcomes through the sharing
of the knowledge we gained.64 (page 75)
Accounting for Canada’s colonial history of
knowledge production
Durie (no date), in his work on an Indigenous model of
health promotion, argues that it challenges traditional
public health models by confronting the colonial his-
tory of knowledge production and the privileging of
a hierarchical notion of power.65 A recent Canadian
study concluded that effective approaches to health
promotion with Indigenous peoples require decoloniz-
ing practices.66 A population health approach has been
cited as supportive to prioritizing Indigenous cultural
understandings, teachings, and practices of healing
and medicine in combination with Western principles
of health research.67 Mundel and Chapman (2010)
wrote that “... a decolonizing approach to health pro-
motion has the potential to address immediate needs
while simultaneously beginning to address underlying
causes of Aboriginal health inequities”.68 (page 166)
In our own work, the sharing of understanding in a
culturally meaningful manner was central; we applied
an Aboriginal method of knowledge translation—
storytelling. Through it we illustrated the disjuncture
between Western and Aboriginal responses to healing
and suggested that it may be a valuable tool for knowl-
edge transfer in the clinical setting as it allows the lis-
tener to see, hear and feel the ndings rather than only
reading about them in a traditional Western venue
(academic journal, physician pamphlets) or being told
about them by a physician.69 (page 75)
Accounting for First Nations self-determination
The health promotion framework’s attention to indi-
viduals’ negotiation of their health has been identied
as a form of “health self-determination”70 and must
also be understood within a broader context, that is
‘self’ is also interpreted to represent ‘First Nations’
as a collective and also within the context of envi-
ronment such as the social determinants of health.
Self- determination requires opportunities to improve
capacity through access to culturally relevant services
with self-empowerment as the goal. This is a neces-
sary condition for socio-economic development71

Dell et al
28 Substance Abuse: Research and Treatment 2012:6
and is congruent with First Nations’ understanding of
attempts to secure self-determination for their individ-
ual and collective wellbeing.72–74 A central feature of
health promotion, community empowerment, coincides
with self-determination; “At the heart of this process is
the empowerment of communities—their ownership
and control of their own endeavours and destinies”.75
(page 3) Manifestations of self-determination were
exercised in multiple ways in the From benzos to
berries project, including it’s initiation from a com-
munity-identied need through to community co-
authorship on the resultant paper. This latter point is an
important consideration, as we concluded that there is
a signicant need for peer-reviewed, culturally compe-
tent, psychiatric research.76 (page 75)
Recommendations for Moving
Research Forward on Prescription
Drug Misuse
Addressing intentional psychotropic drug misuse
among First Nations in Canada demands an
acknowledgement of the fundamental inequalities
faced by First Nations communities that are evidenced
by the disparities in the determinants of health and in
Canada’s colonial history of knowledge production.
Alternatively, research must also recognize the pro-
tective inuence of traditional First Nations culture
has on overall health and wellbeing and the impor-
tance of First Nations self-determination in research.
As illustrated, to engage in decolonized research, it
is necessary to establish an ‘ethical space’ in which
Western health and First Nations understandings of
wellbeing can be considered alongside one another.
Based on this understanding, three recommenda-
tions are made for moving research forward that can
inform the development of culturally appropriate
understandings of, and responses to, prescription drug
misuse. It is important that these recommendations
be reviewed in the context of existing and on-going
action in Canada (eg, CCSA’s initiation of a national
strategy, Ontario’s First Nations Prescription Drug
Abuse Strategy, implementation of the Honouring
Our Strengths Renewal Framework).
1. With the health promotion framework amenable
to accounting for the protective inuence of First
Nations traditional culture and the detrimental
health impacts of colonization, including Indigenous
determinants of health, it is recommended that
research likewise account for a strengths-based
approach to understanding First Nations encoun-
ters with problematic psychotropic drug use. For
example, between 2006 and 2009 Drug Utilization
Prevention and Promotion pilot projects were under-
taken in various regions of Canada. The Timiskam-
ing First Nation Community initiative in Quebec
focussed on motivating healthy behaviour and life-
styles related to prescription drugs by promoting
traditional behaviours and enhancing self-esteem.77
In order to measure the success of these health
interventions, it is necessary to acknowledge and
assess the impacts of community-based traditional
approaches, such as Medicine Wheel teachings that
account for the mental, physical, emotional and
spiritual aspects of wellbeing, alongside Western
indicators of effectiveness (which tend to be more
decit based, such as measuring an absolute reduc-
tion in prescription drug misuse).
2. With the colonial history of knowledge production
in Canada recognized from within a health promo-
tion framework, it is recommended that research
support a participatory-action approach that places
the First Nations community at the centre of the
research process, and which demonstrably upholds
the ownership, control, access and possession
principles of First Nations research.78 As the First
Nations Information Governance Centre has dem-
onstrated with the collection of health prevalence
data, and others have established with qualitative-
based studies (see Acoose et al),79 this can be
accomplished in both methodological realms. This
will be necessary for the establishment of baseline
data in the prescription drug misuse eld and the
evaluation of consequent practice-based response;
it will be important to know why prescription drugs
are being misused (eg, demand ranging from pur-
poseful misuse to addiction from legitimate pain
medication) to how they are being attained (supply
ranging from overprescribing, inappropriate pre-
scribing, to illegitimate sources).
3. With recognition within the health promotion
framework that self-determination can effectively
empower First Nations and contribute to wellbe-
ing, it is recommended that community members,
including traditional Elders, assume leadership
roles throughout the research process.

Prescription drug misuse among First Nations
Substance Abuse: Research and Treatment 2012:6 29
Precedent research projects can be turned to for their
leadership and lessons in prioritizing the wisdom and
knowledge of traditional Elders80 (see Bourassa et
al).81 Community-based research ethics boards devel-
oped and run by First Nations communities are also a
good example to learn from (eg, Six Nations Council
Ethics Committee).82
As the research history with First Nations in
Canada has shown generally, attempts to move for-
ward must be owned by the community and be based
within community history and cultural knowledge,
which in turn has the potential to help build cultural
capacity to develop effective prevention and response
efforts. Health promotion is not being proposed as
the denitive framework to address the limitations
of past research approaches, but it is presented as a
potential beginning point or framework for address-
ing prescription drug misuse within which both
Western and Indigenous worldviews can be consid-
ered. Although the framework has limitations (eg,
foundation in Western thought), recognizing it as a
beginning point has the potential to contribute to the
development and evaluation of more suitable com-
munity-driven culturally-based responses that may
ultimately improve First Nations health and wellbeing.
Author Contributions
Conceived and designed the original research: CAD,
CH, DD. Analysed the data: CAD, CH, DD. Wrote the
rst draft of the manuscript: KT, CD, GR, JK. Con-
tributed to the writing of the manuscript: MD. Agree
with manuscript results and conclusions: CAD, GR,
JK, KT, MD, CH, DD. Jointly developed the struc-
ture and arguments for the paper: CAD, GR, JK, KT,
MD, CH, DD. Made critical revisions and approved
nal version: CAD, JK, MD, CH, DD. All authors
reviewed and approved of the nal manuscript.
Funding
Ofce of the Research Chair in Substance Abuse,
University of Saskatchewan, funded by a grant from
the Ministry of Health.
Acknowledgements
The foundation for this paper was established in a
2007 Health Canada report titled Informing Next
Steps: A Review of Health Promotion and Interven-
tion Strategies Addressing Prescription Drug Abuse
among First Nations in Canada, authored by C. Dell,
G. Roberts and J. Kilty for the Community Programs
Directorate of the First Nations and Inuit Health
Branch. The From benzos to berries project illus-
tration used in this paper was originally undertaken
by C. Dell, M. Seguin, C. Hopkins, R. Tempier, L.
Mehl-Madrona, D. Dell, R. Duncan and K. Moiser
and published in 2011 in the Canadian Journal of
Psychiatry.
Disclosures and Ethics
As a requirement of publication author(s) have pro-
vided to the publisher signed conrmation of compli-
ance with legal and ethical obligations including but
not limited to the following: authorship and contribu-
torship, conicts of interest, privacy and condential-
ity and (where applicable) protection of human and
animal research subjects. The authors have read and
conrmed their agreement with the ICMJE author-
ship and conict of interest criteria. The authors have
also conrmed that this article is unique and not under
consideration or published in any other publication,
and that they have permission from rights holders
to reproduce any copyrighted material. Any disclo-
sures are made in this section. The external blind peer
reviewers report no conicts of interest.
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