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International Journal of Child and Adolescent Resilience Violence and Resilience: A Scoping Review of Treatment of Mental Health Problems for Indigenous Youth

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Indigenous communities have sustained multiple layers of trauma across generations in their lands and social ecology. Considering services utilization as a potential resilience process and cultural as a resilience resource, Western mental health approaches have been modified and applied to Indigenous youth. A scoping review framework was utilized to explore the available research evidence regarding mental health treatment for Indigenous youth; eight articles were reviewed. The majority of interventions were based in a Cognitive Behavioural Therapy model. These interventions were effective and perceived as culturally acceptable. The results support incorporating traditional cultural activities in the treatment of mental health concerns. Development of traditional and cultural applications, especially those that may serve to bolster resilience, and measuring resilience as an outcome, is needed. Acknowledgement:
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48 Copyright © 2016 International Journal of Child and Adolescent Resilience
International Journal of Child and Adolescent Resilience
Violence and Resilience: A Scoping Review of
Treatment of Mental Health Problems for
Indigenous Youth
Alexandra S. Drawson1, Carolyn Houlding2, Peter Braunberger3, Erica
Sawula1, Christine Wekerle4, and Christopher J. Mushquash5,6,
1 Lakehead University
2 Dilico Anishinabek Family Care
3 St. Joseph’s Care Group, Northern Ontario School of Medicine
4 McMaster University
5 Lakehead University, Northern Ontario School of Medicine.
6 Corresponding author: Chistopher Mushquash, Ph.D., C. Psych., Associate Professor, chris.mushquash@
lakeheadu.ca, tel: 807-343-8257, fax: 807-346-7734.
Abstract:
Indigenous communities have sustained multiple layers of trauma across generations in
their lands and social ecology. Considering services utilization as a potential resilience
process and cultural as a resilience resource, Western mental health approaches have
been modified and applied to Indigenous youth. A scoping review framework was
utilized to explore the available research evidence regarding mental health treatment
for Indigenous youth; eight articles were reviewed. The majority of interventions were
based in a Cognitive Behavioural Therapy model. These interventions were effective and
perceived as culturally acceptable. The results support incorporating traditional cultural
activities in the treatment of mental health concerns. Development of traditional and
cultural applications, especially those that may serve to bolster resilience, and measuring
resilience as an outcome, is needed.
Acknowledgement:
We thank the Canadian Institutes of Health Research – Institute of Gender and Health
funding from a Team grant on boys’ and men’s health (TE3 138302) and funding from
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the Networks of Centres of Excellence Children & Youth in Challenging Contexts
Network (http://cyccnetwork.org). We also thank Mr. Ronald Chung for his assistance.
Dr. Mushquashs involvement in this work is partially supported by the Canada Research
Chairs Program.
Conicts of Interest:
The authors have no conflicts of interest to declare with respect to this manuscript.
Keywords:
Indigenous youth, trauma, resilience, traditional healing
Introduction
The Indigenous1 population in Canada composes 4.3% of the total population and this
proportion is growing rapidly; youth aged 14 and under compose 28% of this population,
while those ages 15-24 account for an additional 18.2% (Statistics Canada, 2011). Across
Canada, 49.3% of First Nations people reside on-reserve, however this does vary across the
provinces (Statistics Canada, 2011). And nearly half of these individuals experience mental
health difficulties, compared to only one-third of the majority Canadian population (First
Nations Information Governance Centre [FNIGC], 2012; Snowshoe, Crooks, Tremblay, Craig,
& Hinson, 2015). This is due, in part, to the sustained rates of sexual and non-sexual violence
for Indigenous youth (25.4% of Indigenous individuals, compared to 19.4% of Non-Indigenous
individuals; Brownridge et al., 2016). The need to bolster mental health resources in meaningful
ways within Indigenous communities has also been recognized (Kielland & Simone, 2014).
Adolescence marks the time when mental health difficulties originate or become
particularly challenging, and the risk for death by suicide is relatively high (Mental Health
Commission of Canada, 2015). Indigenous children are at an increased risk for poor mental
health outcomes, which can be partially attributed to the historical, systemic violence
directed at this group, including physical, sexual, emotional abuse, and neglect in being
removed from family and community, as well as being second or third generation residential
school survivors (Statistics Canada, 2011). Prior generation residential school attendance
impacts contemporary health and well-being for off-reserve First Nations, Métis and Inuit
Canadians (Hackett, Feeny, & Tompa, 2016). This attendance disrupted family relationships
and is part of the sequelae of historical trauma faced by peoples following the displacement of
1 The term “Indigenous” is used internationally to describe those people native to a specific geographic
location. The term “Aboriginal” refers to those peoples who are indigenous to North America and
encompasses First Nations, Métis, and Inuit people (Indian and Northern Affairs Canada, 2002).
48-63 © Drawson, Houlding, Braunberger,
Sawula, Wekerle & Mushquash
50 Copyright © 2016 International Journal of Child and Adolescent Resilience
communities and placement of children outside of community, and an overwhelming burden of
suffering in day-to-day living due, in part, to the context of no, delayed, limited or contentious
resources (Brave Heart, 2003). Second generation survivors of residential schools experience
a variety of poor outcomes directly related to this intergenerational trauma including greater
depressive symptoms and an increased likelihood of attempting suicide (Bombay, Matheson, &
Anisman, 2011; First Nations Information Governance Committee [FNIGC], 2005).
Indigenous children and youth are also subject to re-victimization patterns from child
maltreatment to adult intimate partner violence (Kong, Roh, Easton, Lee & Lawler, 2016).
Poor mental health outcomes arising from this exposure include depressive symptoms and
fearful attachment, raising concern as to how to ensure that a trauma-informed approach
is prioritized and appropriately contextualized (Kong et al., 2016). Children and youth
living within Indigenous communities are also exposed to land-based trauma, where the
ongoing requirement to defend and protect land and water resources is heightened with
environmental concerns over corporate and governments challenges to treaty rights (King,
Smith, & Gracey, 2009; Kirmayer, Gone, & Moses, 2014).
Indigenous women and girls also experience disproportionally greater violence
compared to both non-Indigenous and male counterparts. The results of this violence include
reduction in leadership roles, degraded sexuality, and attempts at undermining resilience
factors, such as connectedness and cultural practices (Oliver et al., 2015). Further, while
homicide rates have declined for the general population, they have remained unchanged for
Indigenous females. In this light, addressing gendered violence is not only a justice issue,
but also a public health concern (Patrick, 2016). Finally, there are challenges to effectively
obtained federally-approved supports for health.
It is clear the Indigenous peoples in Canada, particularly youth, have been and
continue to be exposed to various forms of violence and trauma, which in turn result in
results in poor mental health. Therefore, it is important that researchers and clinicians are
engaged in determining relevant interventions that demonstrate long-term improved mental
health and resilience outcomes for victims of these traumas (e.g., sexual abuse survivors,
mindfulness-based therapy; Earley et al., 2014). The focus of the current review is evidence-
based applications for Indigenous youth experiencing traumatic events with the goal to: (1)
determine interventions to support their mental health and resilience, and (2) consider to
what extent Indigenous culture and traditional healing practices have been incorporated.
A scoping review approach was chosen given the relative paucity of empirical evaluations
within Indigenous communities that provided outcome information in both mental
health and resilience-related factors. This approach is appropriate when the evidence base
parameters are unknown and the state of evidence has moved beyond a narrative review,
but has not yet reached the depth necessary for a systematic review (Levac, Colquhoun, &
O’Brien, 2010).
Method
We proceeded through the four sequential steps of a scoping review recommended
by Lande et al. (2011). Candidate studies were identified through a search of the PsycINFO
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database using the search terms (intervention OR treatment OR program) AND (indigenous
OR aboriginal OR first nation* OR native american OR american indian) AND (youth OR
adolescen*) in the title of the articles. This search resulted in 173 articles, four of which
were retained following review of abstracts. Results were limited to peer-reviewed, scholarly
sources. Reference sections of identified treatment and review articles were also manually
searched. As a result of this process, as well as the authors’ involvement in the literature, an
additional four articles were included in this review, for a total of eight studies (see figure 1).
Studies were included if they reported evaluative (quantitative or qualitative) findings
focused on the psychosocial treatment or targeted prevention of mental health disorders in
Indigenous youth. Articles that were exclusively descriptive, including those detailing the
development of culturally based interventions, were not included.
Results
See Table 1 (on following page).
Trauma
Trauma-focused cognitive behavior therapy (TF-CBT) is a well-established intervention
for treating children who have been exposed to trauma (Cohen, et al., 2010; Silverman et al.,
2008), including for culturally diverse youth in foster care (Weiner, Schneider, & Lyons, 2009).
Figure 1: Flow diagram for study selection
Reviewed articles
(n=173)
Reviewed articles
(n=32)
Included studies
(n=4)
Final set of
included studies
(n=8)
Records excluded
(n=197)
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52 Copyright © 2016 International Journal of Child and Adolescent Resilience
Table 1: Results Table
Authors
(year) Name of
Program Sample Char-
acteristics Outcome Measure(s) Findings
Morsette et al.
(2009)
Cognitive
Behavioral
Intervention for
Trauma in Schools
(CBITS)
4 American
Indian youth
Life Events Scale;
Childhood PTSD
Symptom Scale
PTSD & depressive symptoms
were reduced for 75% of students
Morsette et al.
(2012)
Cognitive
Behavioral
Intervention for
Trauma in Schools
(CBITS)
43 American
Indian youth
Life Events Scale;
Childhood PTSD
Symptom Scale;
Children’s Depression
Inventory
67% showed decrease in PTSD
symptoms
38% showed decrease in
depressive symptoms
Goodkind et
al. (2010)
Cognitive
Behavioral
Intervention for
Trauma in Schools
(CBITS)
24 American
Indian youth
Recent Exposure
to Violence Scale;
Childhood PTSD
Symptom Scale;
Children’s Depression
Inventory; Children’s
Coping Strategies
Checklist
Significant decrease in symptoms
of PTSD and anxious symptoms
Slight decrease in depressive
symptoms
Improved symptoms of
depression were maintained at
six month follow-up
Woods & Jose
(2011)
The Kiwi
ACE program
24 Maori and
Pacific youth
Children’s Depression
Inventory
Significant decrease in depressive
symptoms post-treatment and at
one-year follow-up
LaFromboise &
Howard-Pitney
(1995)
The Zuni Life Skills
Development
curriculum
98 Zuni youth Suicide Probability Scale;
Beck Hopelessness
Scale; Indian Adolescent
Health Scale; life skills
(suicide prevention skills,
active listening, problem
solving); Observed
role-play
Participants did not gain skills
within the domains that the
program targeted including
self-esteem, recognizing and
eliminating self-destructive
behaviour, or identifying stress
When assessed via a role-play,
the intervention group was more
skilled in suicide intervention and
problem-solving
May et al.
(2005)
Adolescent Suicide
Prevention Project
American Indian
youth (Western
Athabaskan
tribal nation)
Suicide gestures,
attempts, & completions
Decrease in suicidal gestures and
attempts
No change in deaths by suicide
Le & Gobert
(2013)
Mindfulness-based
suicide prevention
program
8 American
Indian youth
Patient Health
Questionnaire (PHQ-9)
The program was perceived as
helpful
Decreased suicide ideation
Some improvement in depressive
symptoms
Dickerson et al.
(2012)
Drum Assisted
Recovery Therapy
for Native
Americans
6 American
Indian youth
with substance
use disorders,
8 substance
abuse treatment
providers, and
4 community
members
Focus group questions The program was deemed to be
helpful and culturally appropriate
Desmond
(2011)
The Urban Trails
Project
40 American
Indian youth
Child Behaviour
Checklist; Behavioral and
Emotional Rating Scale
Significant decreases in both
internalizing and externalizing
problems
The youth also reported
significant gains in behavioural
and emotional strengths
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Cognitive behavior therapy in schools (CBITS; Jaycox, 2004) has been adapted from TF-CBT,
and is one of the most widely-researched group interventions for youth who have experienced
trauma. CBITS consists of up to ten weekly school-based sessions (4 group session; 3 individual;
2 parent sessions; one teacher session). This program was originally designed for traumatized
immigrant youth in inner-city schools, and has been successfully used to treat youth from
ethnic minorities including African American and Hispanic youth (Stein et al., 2003).
The impact of CBITS delivered by school counselors to American Indian youth with
a high level of exposure to violence and living on-reservation in the United States has been
studied in Montana (Morsette et al., 2009), Nebraska (Morsette, van den Pol, Schuldberg,
Swaney & Stolle, 2012), and in rural New Mexico (Goodkind, LaNoue, & Milford, 2010). In
an initial study with four students, 75% reported substantial decline in PTSD or depressive
symptoms following completion (Morsette et al., 2009). In a subsequent study, 67% of the 43
students who completed the program demonstrated improvements in symptoms of PTSD
and 38% showed improvements in symptoms of depression (Morsette et al., 2012). An intent-
to-treat analysis indicated improvement in PTSD symptoms following and minimal change in
symptoms of depression (Morsette et al., 2012). Goodkind et al. (2010) reported that within
their sample of 24 American Indian youth, there was a significant decrease in symptoms of
PTSD and anxious symptoms, and a slight decrease in depressive symptoms. While gains in
terms of improved symptoms of depression were maintained at six month follow-up, gains in
PTSD symptoms were not (Goodkind et al., 2010).
Suicidality
Woods and Jose (2011) examined the impact of a school based early intervention
program for symptoms of depression in grade ten Maori and Pacific Islander adolescents.
The intervention was the Kiwi Adolescent Coping with Emotions (Kiwi ACE) program, a
cognitive behavioral and psycho-educational intervention. Treatment consisted of eight,
90-minute group sessions facilitated by school counselors. Although the study only reported
results of Indigenous youth, the intervention was offered to students of all ethnicities, and
was not culturally tailored for Indigenous youth. Participants were randomly allocated to
intervention and usual care (i.e., sessions with a school counsellor) control groups, with
data available for 12 participants in each group. Analysis revealed outcomes favoring youth
participating in Kiwi ACE program over those receiving usual care, with greater symptom
reduction post-intervention and at two and 12 month follow ups (Woods & Jose, 2011).
The Zuni Life Skills Development Program (ZLS) is a school-based intervention
program aimed at reducing suicide in Zuni pueblo youth (LaFromboise & Howard-Pitney,
1995; LaFromboise, 2008). The 98 Zuni youth who completed the program reported feeling
less suicidal and less hopeless compared to the youth who did not receive the intervention;
however there was no difference in depression scores between the two groups (LaFromboise
& Howard-Pitney, 1995). The youth who completed the program also did not report any
gains in the skills the program targeted including self-esteem, recognizing and eliminating
self-destructive behaviour, or identifying stress, however when assessed via a role-play, raters
significantly evaluated the intervention group as more skilled in suicide intervention and
problem-solving (LaFromboise & Howard-Pitney, 1995).
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54 Copyright © 2016 International Journal of Child and Adolescent Resilience
One study was completed using the Adolescent Suicide Prevention Project, which
is a public health initiative designed to support American Indian youth in Western
Athabaskan tribal nation in rural United States (May, Serna, Hurt, & DeBruyn, 2005). A
quasi-experimental evaluation found that the implementation of this public health approach
(including universal, selective, and indicated interventions) was associated with substantial
reductions in suicidal gestures and attempts (although not deaths) in youth (May et al., 2005).
An innovative pilot feasibility study examined the acceptability of implementing a
mindfulness-based suicide prevention program with American Indian youth (Le & Gobert,
2013). Eight youth attending a Native American school in rural Montana participated in the
program as part of a more comprehensive, community-wide suicide prevention initiative.
The program was a universal intervention, delivered as a class curriculum, for 55 minutes,
four days a week for nine weeks within a reservation–based school. Mixed method analysis
indicated that program content was perceived as helpful and culturally acceptable by
participants. Participants also reported improvements in mindfulness practice, decreased
suicidal ideation, and slight improvement in symptoms of depression.
Evidence-Based Traditional Activities
American Indian youth participants in one study perceived that participating in
American Indian/Native American traditional activities (through The Urban Trails project)
was helpful in connecting them with the larger American Indian community (Dickerson
& Johnson, 2011). The Urban Trails project was a children’s mental health program for
American Indians, and made use of a culturally informed holistic system of care for
intervention. Forty youth participated in the entire study (including follow-up every six
months for three years) and showed significant decreases in both internalizing (depressive,
anxious, and somatic symptoms) and externalizing (rule breaking and aggressive behaviour)
problems (Desmond, 2011). The youth also reported significant gains in terms of behavioural
and emotional strengths (Desmond, 2011).
Dickerson et al. (2012) conducted a qualitative study examining the perceived
acceptability and helpfulness of Drum Assisted Recovery Therapy for Native Americans
(DARTNA) when used with urban American Indian and Native American youth with
problematic substance abuse. The DARTNA program involved using drumming as part of
a culturally adapted 12-step program, talking circles, and medicine wheel teachings (White
Bison, 2007 in Dickerson et al., 2012). Accommodations were made to address the fact that
drumming is traditionally a male-only activity. The professionals, youth, and community
advisory board members perceived DARTNA to be helpful and culturally appropriate
(Dickerson et al., 2012). Specific benefits included: healing, development of positive cultural
identity, and creating a connection to culture (Dickerson et al., 2012).
Discussion
Widespread family and community disruptions place Indigenous youth at increased
risk of exposure to traumatic events, including abuse and family violence, however it does
appear that there are interventions that may serve to improve mental health outcomes and
resilience following exposure.
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Trauma
Culturally adapted CBITS programs were associated with improvement in mental
health symptoms (Goodkind et al., 2010; Morsette et al., 2009; Morsette et al., 2012). Within
the three implementations of this program, the core content of CBITS was maintained
alongside the cultural adaptations including using culturally relevant examples, adding
native linguistic concepts, embedding local history within the intervention (Morsette et al.,
2009), utilizing stories and examples based on cultural teachings, as well as inviting Native
elders to speak about Native perspectives of trauma, conduct healing ceremonies during
sessions, and conduct ceremonies at the group graduation (Morsette et al., 2012), as well as
considering the appropriateness of speaking about someone who had died (Goodkind et al.,
2010). The majority of students who commenced treatment finished (Goodkind et al., 2010;
Morsette et al., 2012), and counselors reported that they perceived CBITS was an acceptable
match to their community (Morsette et al., 2012). Youth participants also indicated that the
intervention was beneficial and enjoyable (Goodkind et al., 2010).
Goodkind et al. (2010) found that symptoms of PTSD improved during the course
of treatment, but that these gains were not maintained at 6 months post-treatment. They
speculated that this may have been due to experiencing trauma near the end of treatment
or may reflect the chronicity and complexity of the trauma experience in Indigenous youth.
Authors noted, however, that the logistics of gaining approval for the study from tribal
councils, and the process of obtaining consent from participants and their parents was
onerous. There was concern over the proportion of youth who displayed symptoms of PTSD,
but did not participate in the study. For instance, 10% of youth eligible for the intervention
did not participate because they did not feel comfortable with the group format. Further,
many youth who reported high levels of exposure to traumatic events at initial screening were
ultimately not eligible for treatment. Participants who had only experienced sexual abuse,
or whose PTSD symptoms were due to grief or loss as opposed to exposure to violence were
excluded. This criteria may have unfortunately excluded the majority of children, as rates
of poly-victimization in youth are quite high (56.8%); it is likely that if a youth was exposed
to violence, they have suffered another form of victimization (Hamby, Finkelhor, Turner, &
Ormond, 2010).
Authors concluded that while they had made superficial adaptations to CBITS,
given difficulties with recruitment and retention, deeper structural adaptations may be
warranted (Rescinow, Soler, Braithwaite, Ahluwalia, & Butler, 2010). This also highlights the
requirement that program developers consider the ethical implications of youth research
participants who do not consent to become study participants and ensure they have the
proper clinical protocols and individual intervention efforts available for these youth. Given
that TF-CBT is considered a gold standard intervention, further research into assessing its
acceptability and feasibility with Indigenous youth is warranted.
Overall, results of empirical evaluations of treatments to address trauma in Indigenous
youth are promising. However, there are no studies conducted within community agencies.
This is relevant since not all youth are comfortable in group settings, and with the relative
lack of privacy offered within school settings. Further, there is a lack of guidance regarding
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56 Copyright © 2016 International Journal of Child and Adolescent Resilience
treatment planning for youth presenting with comorbid conditions or complex trauma (as
defined as recurrent and cumulative exposure to trauma, which results in a widespread
difficulties in a variety of functions including attachment, emotion regulation, and self-
perception; Courtois, 2004). Difficulty in recruitment and retention suggests a need to
generate strategies to improve youth engagement. Overall, results of the treatment of trauma
in Indigenous youth support the use of manualized CBT based interventions with cultural
adaptations.
Suicidality
Indigenous youth have one of the most elevated risks for suicide in the world
(Kirmayer, 1994). There have been numbers of proposed prevention programs to address this
extremely serious and pervasive issue. Recently a “review of reviews” of suicide prevention
interventions for Indigenous youth was conducted (Bennett et al., 2015). Twenty-eight
reviews of suicide prevention programs were included and a number of recommendations
were generated included the consideration of suicide awareness curriculum in conjunction
with screening, skills and ‘gatekeeper’ training, including peer support. There were no
specific recommendations regarding Indigenous peoples or youth. However, Bennett et al.
(2015) discussed the importance of Indigenous and non-Indigenous service providers to
review the general recommendations in order to determine applicability. The lack of robust
evidence to support particular prevention efforts for Indigenous youth makes on-going
rigorous evaluation of local prevention efforts particularly important (Bennett et al., 2015).
Kirmayer, Fraser, Fauras and Whitley (2009) conducted one the most comprehensive
reviews of suicide prevention programs for Indigenous communities thus far. They identified
30 suicide prevention programs for use with Indigenous populations and, although relatively
few had been evaluated, 11 of them were described as “promising” (Kirmayer et al., 2009).
Key elements, informed by research, emphasized the importance of moving beyond
individual-level interventions to include systems-level initiatives. Kirmayer et al. (2009)
noted that the most important characteristics of programs seemed to be community initiative
and investment in the process, rather than the content of the intervention per se. Given the
work to date, it seems critical that such promising approaches continue within a program of
research to establish best-fit practices for Indigenous communities.
Holistic approaches to suicide prevention also include opportunities to participate in
family and community activities, centered on sharing cultural knowledge and values. This
approach implicitly acknowledges that suicidality can reflect socially-mediated (rather than
psychologically) distress, including cultural and community disruption (Wexler & Gone,
2012). Interest in traditional healing and cultural activities as part of suicide prevention
efforts are consistent with findings that lower rates of suicide within Indigenous communities
are associated with enhanced cultural continuity (Chandler & Lalonde, 2008).
In this paper, four culturally adapted programs aimed at reducing Indigenous youth
suicide were reviewed. Results from all four indicated improved mental health symptoms
and/or reduction in suicidal ideation or gestures following completion (LaFromboise &
Howard-Pitney, 1995; Le & Gobert, 2013; May et al., 2005; Woods & Jose, 2011). Participants
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across all four programs also deemed the cultural adaptations to be acceptable. Most of these
cultural adaptations referred to additions of ceremony or counseling from Elders to the
intervention protocol, however one study examined the acceptability of mindfulness with
American Indian youth (Le & Gobert, 2013). Within this mindfulness program ceremonies
such as smudging and prayer were also incorporated and adaptations deemed appropriate
(Le & Gobert, 2013). The study by May et al. (2005) was also unique in that the researchers
examined trends in data over the eight years that had elapsed since the implementation of
a program for American Indian youth. This population-based research is important for
demonstrating long-term, sustainable effects of suicide prevention programs for Indigenous
youth.
Overall, it appears the seriousness and pervasiveness of the issue of youth suicidality
has driven implementation of prevention measures ahead of evaluation of the effectiveness of
these prevention efforts. Comprehensive programs include awareness; screening; gatekeeping
(peers and primary care providers); and treatment of psychiatric disorders. There is some
limited evidence for incorporation of cultural-specific content within interventions. However,
there is a pressing need for on-going evaluation of any suicide prevention efforts.
Evidence-Based Traditional Activities
A growing number of services and programs are incorporating traditional healing
practices into treatments to address the mental health needs of Indigenous adults and youth.
This is done in a variety of ways (Oulanova & Moodley, 2010; Trimble, 2010); some agencies
use a holistic model of service, whereby a number of intervention components, including
Western and traditional, are made available under the auspices of a single organization
(Nebelkopf & Wright, 2011). Alternatively, there can be active collaboration between Western
therapists and traditional healers, even if this does not occur within the same agency (e.g.
Puchala, Paul, Kennedy & Mehl-Madrona, 2010). Western therapy can be adapted and
augmented to incorporate traditional elements (e.g., culturally-based stories or symbols) to
illustrate concepts within therapies (BigFoot & Schmidt, 2009; Kumpfer et al., 2002; Saylors &
Daliparthy, 2004). Other services focus on participation in traditional healing and culturally-
based activities (such as land-based or drumming) (Dickerson, Robichaud, Teruya, Nagaran,
& Hser, 2012). Lastly, integrative therapies have been developed, whereby a hybrid model of
therapy is generated by integrating Indigenous spirituality with Western-based therapies (e.g.
Duran, 2006 in Gone, 2010).
Oulanova and Moodley (2010) conducted a qualitative study with Canadian
practitioners (7 Indigenous; 2 European origins) to examine the way in which they integrated
traditional healing and Western interventions, when delivering mental health services
to Indigenous adults in Canada. Therapists reported that they generally used their own
judgment to decide when (and whether) to integrate traditional healing methods into
counseling. Interestingly, they also mentioned the helpfulness of traditional healing in the
counselors’ self-care. Other researchers have noted that the involvement of traditional healing
might be perceived as appropriate for some concerns (e.g., emotional distress) but not others
(e.g., infectious diseases) (Wyrostok & Paulson, 2000).
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58 Copyright © 2016 International Journal of Child and Adolescent Resilience
Evaluation of the impact of traditional healing on mental health is limited – possibly
because such studies may be particularly ethically and logistically challenging (Puchala et
al., 2010). Nonetheless, research generally suggests that use of culturally specific-programs
or culturally-adapted elements appears to encourage engagement and retention, although
not necessarily improved outcomes. For instance, a review of counseling literature by
Trimble (2010) suggested that incorporation of cultural elements to interventions improves
development of rapport, trust and empathy. Specific cultural activities that have been used
in therapeutic contexts include talking and sharing circles, smudging, prayer, pow wows,
sweatlodges, drumming, bead and jewelry making, and land-based activities, such as hunting
and tundra walks (Mills, 2003; Nebelkopf & Wright, 2011; Portman & Garrett, 2006). One
pragmatic challenge to incorporating cultural elements in treatments for Indigenous youth is
the diversity of communities and, hence, traditions and ceremonies from which they might
be drawn. The use of healers who can minister across tribes, and selection of and practices
common to many Indigenous communities are some ways to attempt to pragmatically
address this challenge (Dickerson et al., 2012; Hartmann & Gone, 2012).
Several studies also exist that evaluate the helpfulness of traditionally-based
interventions with adult participants. A clinical case series conducted in Aboriginal
communities in Saskatchewan, Canada examined the impact of augmenting psychiatric
care with routine involvement of elders and traditional healers when addressing domestic
violence (Puchala et al., 2010). The work of psychiatric and community healers was
conducted jointly in some instances (e.g., family sessions) and separately in others (e.g.,
praying or ceremonies) While specific content of traditional spirituality was individualized
for each participant, commonalities across cases included adopting a non-judgmental,
non-blaming approach to perpetrators of domestic violence and involving families of both
the perpetrator and the subject of violence in discussions. Therapy involved changing the
narrative and co-constructing a ‘redemptive script’ about the violence. This redemptive
script sometimes included an appeal to values and roles illustrated within traditional stories
(e.g., core Aboriginal values such as respect for women; use of ‘talking circles’, rather than
violence, to solve problems). Sixty-two percent of the adults in the study showed a “dramatic”
improvement in rates of domestic violence, including 29 who had virtually ceased altogether
(Puchala et al., 2010).
Schif and Moore (2006) conducted a quasi-experimental study of the immediate impact
of sweat lodges on adult participants (59% of whom were Indigenous). Consistent with
previous research (Ross & Ross, 1992; Colmant & Merta, 1999), short-term improvements in
spiritual and emotional wellbeing were reported, although there were no follow up ratings.
A retrospective study also examined the accounts of Indigenous adults speaking about their
healing journeys (McCormick, 1995). More than 50% mentioned establishing a connection
with nature as pivotal in their personal journey (McCormick, 1995).
Three articles were included in this review that specifically utilize traditional healing
to address mental health issues and improve resilience in youth. When Indigenous youth
participated in traditional activities, they reported experiencing a greater connection to the
larger Indigenous community (Dickerson & Johnson, 2011; Dickerson et al., 2012). Further, it
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does seem that connecting to culture and engaging in traditional activities can have a positive
impact on mental health outcomes and resilience (ADULT refs). While only one study
evaluated the affect that traditional activities has on youth mental health, significant gains
were made in internalizing and externalizing problems, as well as behavioural and emotional
strengths (which can be viewed as resilience factors; Desmond, 2011).
Despite these positive preliminary results, caution needs to be exercised when
considering incorporation of traditional healing in mental health interventions. Researchers
have warned against non-Indigenous practitioners making use of traditional cultural
practices and some describe this as a form of cultural appropriation (Gone, 2010; LaDue,
1994; Oulanova & Moodley, 2010). Details regarding the specific nature of particular
traditional healing practices might not be documented in writing, to avoid appropriation
(Gone, 2010) or because, in some cultures, it is only appropriate for certain subgroups to
have or make use of knowledge of particular cultural practices (Brady, 1995). Hartmann and
Gone (2012) note that traditional healing activities should be carefully chosen, particularly
with Indigenous youth without extensive previous exposure to traditional activities. There
is also concern that traditional healers be vetted in some way to ensure the authenticity of
their knowledge, and avoid exploitation of Indigenous communities. It is also important to
consider that an introduction to cultural activities per se is not necessarily healing. Success in
addressing addictions and other mental health problems success may be limited by the extent
that peer groups support changes in the youth’s behavior (Brady, 1995). Lastly, Oulanova and
Moodley (2010) mentioned some practitioners were concerned about the potential responses
of their regulatory colleges to use of traditional methods within therapy.
Future Directions
Several interventions have been developed to address the common problems with
which youth typically present, however many of the interventions have often not been
extensively evaluated, and this remains a priority for future work. Many of the studies
included in this scoping review suffered from small sample sizes (Desmond, 2011; Dickerson
et al., 2012; Goodkind et al., 2010; LaFromboise & Howard-Pitney, 1995; Le & Gobert, 2013;
Morsette et al., 2009; Morsette et al., 2012; Woods & Jose 2011), which limited the statistical
analysis that could be completed and conclusions that could be drawn from the findings.
Additionally, none of the studies utilized a randomized controlled trial design. Future
research regarding interventions aimed at enhancing mental health outcomes and resilience
in Indigenous youth should utilize more rigorous methods and statistical techniques to
improve the quality of the evidence.
Surprisingly, there were no interventions directed at youth that utilized alternative or
technology-based delivery methods and as nearly half (49.3%) of First Nations people in
Canada live on-reserve, this format for intervention may be appropriate (Statistics Canada,
2011). Therefore, future research in this area should consider other formats for treatment
delivery including bibliotherapy, computers (and DVDs), the internet, telephone and/or
telehealth. A recent review of 11 self-directed interventions to prevent externalizing disorders
in children found that self-directed interventions to reduce externalizing behaviors in youth
48-63 © Drawson, Houlding, Braunberger,
Sawula, Wekerle & Mushquash
60 Copyright © 2016 International Journal of Child and Adolescent Resilience
generated large effect sizes for parent-reported child externalizing behavior, when compared
to wait-list control groups (Tarver, Daley, Lockwood, & Sayal, 2014). Unfortunately, there
were no comparisons between the effectiveness of self-directed and in-person therapy for
externalizing disorders in youth (Tarver et al., 2014). A recent review with adults with mental
health difficulties revealed that cognitive behavior therapy (CBT) delivered in alternate
formats could achieve comparable outcomes to those delivered face-to-face (Andrews,
Cujipers, Craske, McEvoy, & Tiov, 2010). Of course, utilizing alternative delivery for
treatments comes with additional challenges regarding literacy, computer or internet access,
and confidentiality. Despite these caveats, it is possible and likely that use of books, DVDs,
internet sites, telehealth. and other resources may be helpful adjuncts for a proportion of
Indigenous rural and remote populations, and are consistent with a public health model
for intervention where higher functioning individuals can be assisted with more minimal
support (Currie, McGrath, & Day, 2010).
Conclusion
Indigenous youth are at increased risk of mental health challenges and it is imperative
that this risk is addressed in an evidence-based way. Unfortunately, the quantity and quality
of evidence available to bolster mental health and resilience in youth, particularly those
exposed to violence or trauma, is low. Many studies had small samples sizes and none
employed more rigorous statistical techniques. Therefore, the conclusions that can be drawn
from results are limited. Despite these drawbacks, many studies reported positive feedback
from youth and relevant adults regarding the cultural adaptations made to enhance suitability
of the programming. The depth of these adaptations ranged from minimal to quite deep;
this range included encouraging Elders to attend intervention sessions (Morsette et al.,
2009; Morsette et al., 2012), incorporation of traditional healing ceremonies (Goodkind et
al., 2010) or cultural norms (LaFromboise & Howard-Pitney, 1995; LaFromboise, 2008),
involvement of tribal leadership (May et al., 2005), and the utilization of cultural stories (Le &
Gobert, 2013).
In sum, there is evidence that adapted interventions with widely established empirical
bases in other cultures are helpful when used with Indigenous youth and their families,
particularly for youth who have experienced trauma. This review draws upon the small, but
growing body of literature documenting the benefits of adaptive interventions to suit the
needs of Indigenous youth.
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... Existing research on resilience in indigenous populations attribute indigenous need for resilience to their colonial history (Steele, 2018), maltreatment within the family or community (Jaffee et al., 2007), land-based traumas (the need to fight for and defend their land against government and other institutions; Drawson et al., 2016), or war trauma (Suarez, 2013). As previously mentioned in this paper, indigenous youth populations face a multitude of different challenges that negatively impact their optimal development and well-being (Jaffee et al., 2007;Perera et al., 2016;Steele, 2018;Suarez, 2013). ...
... There are several limitations to this study consistent with limitations across pre-existing research and literature reviews. Small sample size has been the most substantial and consistent limitation across the majority of the research gathered from indigenous populations in Latin America, and specifically within Peru (Castro Solano, 2014;Drawson et al., 2016;McGrath, 2015a;Park & Peterson, 2006;Park et al., 2004;Perera et al., 2016;Proctor et al., 2011;Seligman et al., 2004;Webb, 2014;). Small sample sizes do not provide the best results for the generalization of research findings beyond the group studied (McGrath, 2015a (McGrath, 2015a). ...
... Martínez-Martí & Ruch, 2017) due to their need to cope with increased hardships related to strict traditional gender roles and domestic violence(Drawson et al., 2016; Espinosa et al., 2017 [Abstract only];Heaton & Forste, 2008; OECD, 2019;Perera et al., 2016;Seligman et al., 2004;Stevens, 1973). However,Perera et al. (2016) found that having a strong, positive sense of ethnic identity contributes to individual resilience among Latin Americans. ...
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... Previous research attributes the need for resilience in Indigenous populations to their colonial history (Steele, 2018), maltreatment within the family or community (Jaffee et al., 2007), land-based traumas (Drawson et al., 2016), or war trauma (Suarez, 2013). Perera et al. (2016) found that having a strong sense of ethnic identity contributes to individual resilience among Latin Americans, which is crucial for Indigenous populations because it functions as a protective factor against discrimination, oppression, and marginalization. ...
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