CLINICAL PERSPECTIVES ON THE INTEGRATION OF MAINSTREAM
MENTAL HEALTH APPROACHES AND TRADITIONAL ABORIGINAL
HEALING PRACTICES

by

Marcela Rojas
B.A., Western Baptist College, 2002

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE DEGREE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2014

© Marcela Rojas, 2014

UMI Number: 1525705

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Abstract

The purpose of my thesis was to describe the perspectives of child and youth mental
health clinicians on the integration of mainstream mental health approaches and traditional
Aboriginal healing practices. Research participants consisted of four clinicians currently
employed by the Ministry o f Children and Family Development, who have delivered services
in the Northern region o f British Columbia within the last twelve months. The literature
review examined a variety o f topic related areas, including: Cultural Safety; Research
Considerations; Aboriginal Mental Health; Mainstream Mental Health Approaches;
Traditional Aboriginal Healing Practices; Integrated Mental Health Approaches; and
Considerations for Rural Practice. I applied a qualitative research approach, guided by the
tenets of a constructivist lens.
The process of examining my research findings involved the application of a
Thematic Analysis approach. My research findings support the need for future research that
would expand the scope and applicability of findings. These findings suggest that clinicians
see the value o f integrated approaches in both their practice and in outcomes for their clients.
In addition, findings suggest that clinicians perceive the limitations of mainstream
approaches as potential barriers to the efficacy o f therapeutic interventions. Implications
related to the field o f social work include the institution of organizational specific cultural
safety training and shifts towards more flexible and collaboratively based service delivery
structures.

Acknowledgements

The process of conceptualizing, developing, implementing, and completing this
research was one o f inherent collaboration. I would like to first acknowledge the invaluable
guidance and support o f my thesis supervisor Professor Joanna Pierce, whose patience and
expertise supported me in navigating the intricacies of this process, ultimately leading to the
successful completion of a Master o f Social Work thesis.
In addition, I would like to humbly and gratefully acknowledge the support of my
committee members Dr. Glen Schmidt and Dr. Linda O’Neill. Their valuable guidance
helped shape the scope and direction of my work, while supporting me in finding my voice
as a novice researcher.
Lastly, but certainly not least, I must acknowledge the unwavering support o f my
loving partner and my wonderful friends, whose constancy, patience, and encouragement
made it possible for me to embark on this journey and come out the other end with a sense of
balance and purpose.

Table of Contents
A b stra c t.................................................................................................................................................. i
Acknowledgements.............................................................................................................................. ii
Table of C ontents................................................................................................................................ iii
C hapter One: Introduction.................................................................................................................1
Significance of the Issue....................................................................................................................2
Research Purpose and Objectives.....................................................................................................3
The Personal Context......................................................................................................................... 5
Definitions...........................................................................................................................................6
Summary............................................................................................................................................. 8
C hapter Two: L iterature Review...................................................................................................... 9
Defining Cultural Safety: Initiatives in Policy and Programming................................................. 9
Research Considerations..................................................................................................................15
Aboriginal Mental H ealth................................................................................................................18
Mainstream Mental Health Approaches........................................................................................ 24
Traditional Aboriginal Healing Practices...................................................................................... 32
Integrated Mental Health Approaches........................................................................................... 37
Considerations for Rural Practice...................................................................................................53
Summary...........................................................................................................................................55
C hapter Three: Theoretical O rientation and M ethodology.......................................................57
Research Q uestion........................................................................................................................... 58
Research Population and Sampling.................................................................................................59
Ethical Concerns.............................................................................................................................. 60
Data Collection........................................................................:....................................................... 63
Data Analysis....................................................................................................................................64
Credibility......................................................................................................................................67
Transferability............................................................................................................................... 67
Dependability................................................................................................................................ 67
Confirmability............................................................................................................................... 67
Summary........................................................................................................................................... 69
C hapter Four: Research Findings...................................................................................................71
Thematic Findings........................................................................................................................... 71
Figure 1 ............................................................................................................................................. 72
Themes.............................................................................................................................................. 74
1.

Relationships......................................................................................................................... 74

2.

Historical factors................................................................................................................... 76

3.

Political drivers..................................................................................................................... 77

4.

Supports................................................................................................................................. 78

5.

R oles...................................................................................................................................... 79

6.

Environment...........................................................................................................................80

7.

Approaches............................................................................................................................81

Additional Considerations.............................................................................................................. 82
Summary...........................................................................................................................................83
C hapter Five: Discussion, Implications, and Recommendations.............................................. 84
Discussion.........................................................................................................................................84
Links to Literature............................................................................................................................ 87
Implications for Social Work Practice........................................................................................... 87
Organizational.............................................................................................................................. 88
Practical.........................................................................................................................................89
Academic.......................................................................................................................................89
Limitations o f the Research.........................................................................................................90
Recommendations............................................................................................................................ 90
Summary.......................................................................................................................................92
Conclusion........................................................................................................................................92
Reference List..................................................................................................................................... 94
Appendix A:

Inform ation L e tte r.............................................................................................103

Appendix B:

Consent F o rm ..................................................................................................... 106

Appendix C:

Interview Q uestionnaire................................................................................... 108

Appendix D :

REB Approval L etter.........................................................................................109

1

Chapter One: Introduction

In addressing the mental health needs of Aboriginal populations, professionals are
encouraged to adopt culturally relevant approaches to service delivery. These methods
should reflect standards o f practice that embody conceptual frameworks for cultural safety.
Culturally safe frameworks support practical applications that acknowledge Aboriginal
perspectives concerning the interconnectedness between the physical, mental, spiritual, and
emotional components o f human existence (Aboriginal Canada Portal, 2012).
The health needs o f Aboriginal populations in North America reflect a unique mosaic
of cultural traditions and historical trauma. Traditional Aboriginal healing practices reflect
cultural ideologies concerning social and emotional wellness. These traditional practices
support a holistic approach to promoting health and well-being (Aboriginal Canada Portal,
2012 ).

Mental health professionals tasked with the delivery o f interventions and supports that
improve outcomes for Aboriginal populations must be well informed about culturally safe
frameworks of practice and culturally derived views concerning health and well-being. In
acknowledging the importance of cultural safety, mental health professionals have sought to
integrate mainstream mental health approaches and traditional Aboriginal healing practices.
Traditional healing practices may include, but are not limited to: sweat lodges, smudging,
talking circles, healing circles, and Indian medicines (Henderson, 2008). These holistic
approaches are believed to promote improved outcomes for Aboriginal mental health service
users (Alberta Mental Health Board, 2006).
My research was concerned with describing the perspectives and experiences of child
and youth mental health clinicians in delivering integrated approaches. The goal of my

research was to examine a variety of factors, including systemic, professional, and personal,
such as childhood experiences and cultural influences that may serve to promote, or
challenge, the implementation of integrated approaches. Additional objectives included the
examination of clinical perspectives on the impact of these strategies on the mental wellness
of Aboriginal clients, as well as, the impact of these interventions on non-Aboriginal clients.

Significance of the Issue

In recent decades, professionals in the field of mental health have called attention to the
importance of giving suitable consideration to cultural and ethnic factors within the context
o f clinical interventions. Despite field guidelines concerning the implementation of
culturally competent approaches, limited practical information is available on how to
approach the cultural needs of diverse populations (Bernal & Saez-Santiago, 2006).
My research included a review and analysis of historical factors, cultural
considerations, health ideologies, practice realities, geographical considerations, and the
convergence of modalities. In my research scope I sought to capture factors that may affect
the experiences o f child and youth mental health clinicians concerning the delivery of
integrated approaches. The scope of my research also considered factors that may impact the
clinician's work environment, including available supports and client response, as well as the
clinician's experience in integrating mainstream approaches and traditional healing practices.
My research revealed a lack of detail in policies pertaining to the delivery of mental
and behavioural health services, specifically around the delivery o f culturally safe services.
Another shortcoming is noted in the commonly found definition of cultural safety (Canadian
Institute for Health Information, 2013, p.91; Centre for Aboriginal Health Research, n.d.;
First Nations Health Council, 2012; National Native Addictions Partnership Foundation,

3
2011, p. 95; Smye & Mussell, 2001), which is defined from a westernized perspective and
may fail to capture the nuances o f the various cultures that comprise Canadian society.
In regards to integrated approaches, policies and program guidelines do not appear to
provide detailed direction as to how the process of integration is to occur, what it should look
like, or how it may need to be adjusted in order to meet the unique needs of Aboriginal
populations (Bernal & Saez-Santiago, 2006). Mental health professionals appear to face
limited supports in both the development and implementation o f integrated approaches.
At the initial stages of this process I suspected that my research may leave me with
many more questions than answers, a prospect that the emerging researcher in me looked
forward to as far as the realm of opportunities that possibility could provide. To my surprise
many o f the questions that arose were satisfactorily answered, others remained unanswered,
but offered exciting possibilities for future research. I will explore this further in Chapter
Five: Discussion, Implications, and Recommendations.

Research Purpose and Objectives
The purpose of my research was to describe the experiences and views of mental health
clinicians concerning the merger o f Aboriginal traditional healing practices and mainstream
mental health approaches through an integrated model of service delivery. This information
may serve to promote an improved understanding on the realities, from a clinical perspective,
of implementing integrated approaches in the delivery of mental health services. This
understanding may serve to promote the examination and consideration of systemic barriers;
explore training opportunities and how these coincide with the needs of practicing clinicians;
the impact of clinical support and supervision; and consider the value of existing frameworks
for practice that support the delivery of integrated approaches. The purpose of my research

4
was supported through the identified project objectives. The proposed research objectives
are identified as follows:
•

To describe professional experiences specific to the implementation of integrated
approaches to mental health service delivery

•

To describe integrated approaches and the degree to which they support the
constructs of established culturally relevant priorities in local and national policies

•

To increase awareness and understanding of how traditional Aboriginal healing
practices and mainstream approaches have come together to create a unique form of
service delivery

•

To describe how existing systems support or fail to support the development and
delivery o f integrated approaches to mental health service delivery

•

To describe professional perspectives on the impact of integrated approaches on both
Aboriginal and non-Aboriginal client outcomes
My research was guided by the research question: What are the challenges and

benefits to integrating traditional Aboriginal healing practices and mainstream mental health
approaches? The research question was supported and enhanced by the interview questions.
The interview questions sought to further the project objectives by exploring detailed
experiences and information that further enhance the research question’s scope. These
queries were used to guide the data gathering process. The following are the research
interview questions:
1. What limitations do mainstream mental health approaches present in delivering
culturally relevant supports to Aboriginal clients?
2. Please provide examples o f instances when mainstream mental health approaches did
not work for Aboriginal clients.

5
3. How did you learn about integrated strategies?
4. Please describe your experience in implementing integrated mental health supports.
5. Describe how you learned to implement integrated mental health supports?
6. How did you know it was appropriate to use these strategies?
7. How have integrated mental health supports worked for your clients?
8. What do you believe are the deficits and strengths of integrated mental health
strategies?
9. Were you supported in implementing these strategies? If so, how?
10. Have you encountered systemic challenges while trying to implement integrated
strategies?
The process was substantiated by a review of applicable terms and concepts, historical
factors, and considerations associated with the uniqueness of Aboriginal cultures. Careful
consideration was given to the role and influence of colonization on the emotional health of
Aboriginal peoples. Furthermore, attention was given to the complex field of mental health,
modem mainstream interventions, and support trends. Traditional practices and their
approach to mental health were also explored. The methodology and research approaches
are a key component o f this process and were therefore carefully examined.

The Personal Context
The process of identifying the stance from which research is being conducted lends
credibility to the tone o f the research. This research sought to provide a sense of
transparency concerning the researcher’s motives and impact on the outcomes of the project
(White, Drew, & Hay, 2006).

6
My purpose and vision concerning this research stems from a desire to discover,
explore, and promote culturally relevant approaches in the delivery o f mental health services.
The direction o f my focus reflects a personal background as a first generation Latin
American o f Spaniard heritage, with a diverse background in multi-cultural exposure through
both personal and professional experiences. These experiences helped to shape keen
sensitivities concerning cultural relevance and safety in all forms of practice with a specific
focus on the helping professions.
My professional background has played a key role in shaping the focus of my
advanced educational pursuits. This background includes over seventeen years in the social
services field in various capacities, including addictions treatment; work with incarcerated
populations, community development, and child welfare practice. Having the opportunity to
work with minority populations through rigidly established bureaucratic structures evoked a
personal interest in challenging these systems and learning more appropriate and effective
ways in which to reach these populations.
Embarking on this research has also granted me an opportunity to develop my skills as
a researcher, an opportunity that I am grateful and energized about. I look forward to
developing my knowledge and competence in conducting meaningful qualitative research.
The process has offered a wealth of insight into the complexities of data gathering, the
benefits of knowledge expansion, and the importance of contributing to the academic body of
knowledge.

Definitions
Key definitions are as follows: Aboriginal Peoples is defined as "a collective name
for all of the original peoples of Canada and their descendants" and "consists of three groups

7
- Indian (First Nations), Inuit and Metis" (National Aboriginal Health Organization, 2012).
The term Aboriginal is also considered "the least contentious and most inclusive general term
currently used in Canada" (Kesler, n.d.). Anti-oppressive practice is defined as "recognizing
power imbalances and working toward the promotion of change to redress the balance of
power" (Dalrymple & Burke, 1995). Cross-cultural practice is described as a practical
approach that incorporates "four key elements, including awareness and knowledge of other
cultures, an awareness o f how our own culture influences our perceptions and practice, skill
development in appropriate culturally safe responses in relation to another culture, and a
commitment to social justice and anti-racist practice" (The Lowitja Institute, 2007). Cultural
competency is defined as successful evidence that the service provider demonstrates
awareness in relation to their worldviews and attitudes regarding cultural differences, as well
as knowledge and willingness to understand the contextual reality of the client (National
Native Addictions Partnership Foundation, 2011). Cultural safety is defined as a process that
fosters professional competency that facilitates communication and relational approaches
within the context o f the professional, patient relationship and exemplifies sensitivity and
understanding o f "social, political, linguistic, economic, and spiritual issues" (Ministry of
Health, 2007, p. 195). Culture is defined as "patterns, explicit and implicit, of and for
behavior acquired and transmitted by symbols, constituting the distinctive achievements of
human groups, including their embodiments in artifacts; the essential core o f culture consists
o f traditional (i.e. historically derived and selected) ideas and especially their attached
values" (University o f Minnesota, 2013). Ethnicity is defined as "all those social and
psychological phenomena associated with a culturally constructed group identity” (Baumann,
2004). Mental health is defined as “a state of well-being in which the individual realizes his
or her own abilities, can work productively and fruitfully, and is able to make a contribution

8
to his or her community” (New Brunswick Department of Health, 2011, p. 2).
Multiculturalism is defined as an "ideology on the part of individuals or government that
ethnic, racial, cultural and religious diversity should be celebrated" (Erskine, 2010). Race is
defined as "a class or kind o f people unified by shared interests, habits, or characteristics"
(Merriam Webster, n.d.). Racism is "the belief that all members of a purported race possess
characteristics, abilities, or qualities specific to that race, especially so as to distinguish it as
inferior or superior to another race or other races" (Hoyt, 2012).

Summary

My research explored professional perspectives and experiences concerning the
integration of mainstream mental health approaches and traditional Aboriginal healing
practices, including the impact o f these strategies on the mental wellness of both Aboriginal
and non-Aboriginal clients. I gave additional consideration to the impact of systemic,
professional, and personal issues on participant experiences, as related to the implementation
o f integrated tactics. My research was guided by the identified objectives and research
queries, while the research subjects’ personal context and ethical considerations served to
further refine the overall tone and direction.

9

Chapter Two: Literature Review

An abundance of research is available on approaches to health and well-being from
both indigenous and western perspectives. Attention has also been given to the importance
o f delivering culturally relevant services in the field of mental health. However, the link
between western and indigenous approaches to mental health and how this supports the
delivery o f culturally relevant services is not equally addressed. This section is concerned
with supporting the bridging of this gap through a review and analysis of available literature
on the following areas o f interest: Research considerations, defining cultural safety:
initiatives in policy and programming, Aboriginal mental health, integrated mental health
approaches, traditional healing practices, mainstream mental health approaches, and
considerations for rural practice.

Defining Cultural Safety: Initiatives in Policy and Programming
The conceptual framework for cultural safety is rooted in the work inspired by the
Maori people o f New Zealand in the 1980s, reflecting this population's dissatisfaction with
the delivery of health services. Practical applications that reflect the priorities of this
framework will exhibit recognition for the interconnectedness between the physical, mental,
spiritual, and emotional aspects of the self. Canadian policies providing guidance for the
delivery o f health related services to Aboriginal populations assert that the conceptual
framework for cultural safety may be a helpful tool in guiding the development of strategies
and practical service applications (Canadian Institute for Health Information, 2013).
The importance o f cultural safety and competence is further substantiated by the work
o f the National Native Addiction Partnership Foundation (National Native Addictions
Partnership Foundation, 2011) through their Renewed Framework to Address Substance Use

10
Issues Among First Nations People in Canada, which provides pertinent information and
advice on the delivery of mental health and addiction services that bear evidence of cultural
competency and safety. A working definition o f both safety and competence within the
cultural context serves to strengthen the Foundation's platform. Cultural competency is
defined as successful evidence that the service provider demonstrates awareness in relation to
their worldviews and attitudes regarding cultural differences, as well as knowledge and
willingness to understand the contextual reality of the client (National Native Addictions
Partnership Foundation, 2011). This literary resource further asserts that cultural
competency may serve to support cultural safety. The notion of cultural safety is defined by
the level of reflection at both the individual and organization level, concerning cultural and
historical differences, with recognition for power differentials (National Native Addictions
Partnership Foundation, 2011).
National and provincial government sponsored initiatives have put forth directives for
the establishment and development of culturally safe programming in the delivery of mental
and behavioural health services. These directives further the notion of cultural safety within
an Indigenous context. Cultural safety is described as a process that fosters professional
competency that facilitates communication and relational approaches within the context of
the professional, patient relationship and exemplifies sensitivity and understanding of
"social, political, linguistic, economic, and spiritual issues" (Ministry of Health, 2007, p.
195).
Canada's response to improving the delivery of supports and services to Aboriginal
populations through culturally safe policies and programming is exemplified through the
priorities set forth in 2006, by the Tripartite Agreement. The Agreement reflects the
collaborative efforts of the government of British Columbia, the First Nations Leadership

11
Council, and the government o f Canada. The Agreement gives direction to the collaborative
and coordinated efforts o f federal and provincial entities in their commitment to improving
health outcomes for the Aboriginal populations of British Columbia (Ministry of Health,
2007).
In the spirit of the Tripartite Agreement and through the efforts of the government of
British Columbia and the First Nations Leadership Council, a provincial agreement was
reached, resulting in the inception and implementation of the bilateral Transformative
Change Accord: First Nations Health Plan. The Accord reflects the principles established
through the Tripartite Agreement, making a commitment to provincially delivered
programming that respects and recognizes the unique needs of Aboriginal people; is
committed to active efforts towards bridging the gap in health outcomes for Aboriginal
populations in British Columbia; cultivates rapport between government entities and
Aboriginal partners; and bears evidence of transparency in all transactions (Ministry of
Health, 2007).
The need and value o f culturally safe programming is further supported through the
efforts and recommendations o f their discussion paper titled “Aboriginal Mental Health
Committee and as presented through their Aboriginal Mental Health: What Works Best”.
The recommendations put forth by the committee suggest the need for a process of
transformation that promotes mental health services and programming that recognizes the
uniqueness of the Aboriginal context and supports the delivery of culturally safe supports.
Noteworthy to the efforts of the Aboriginal Mental Health Committee is their admission that
the project's recommendations may not be reflective of Aboriginal perspectives (Smye &
Mussell, 2001). The limitations in the materials and recommendations generated by

12
primarily non-Aboriginal sources prompt the search for Aboriginal perspectives and
authorship concerning culturally safe policies and practice.
Academic acknowledgment for the need to create consistent competency standards in
Indigenous public health evaluation and research prompted the formation of a collaborative
partnership between a Canadian institution for higher learning, the University of Victoria,
and Aboriginal scholars around the world, including Australia, New Zealand, Canada, and
the United States. The Competencies for Indigenous Public Health, Evaluation, and
Research (CIPHER) program aspires to “decipher” cultural safety through public health
competencies that support Aboriginal healthcare. CIPHER'S conceptualization of cultural
safety includes the acknowledgement o f the historical factors that contributed to hostilities
between settler and Aboriginal cultures, examines inequalities, considers the influences of
colonialism on institutional structures, and informs health care practice that acknowledges
the unique attributes and identity of the client population (University of Victoria Centre for
Aboriginal Health Research, n.d.).
The B.C. First Nations Health Council is comprised of representatives from First
Nations political organizations in B.C. The formation of the Council was supported through
various national and provincial level initiatives, including the Transformative Change
Accord: First Nations Health Plan, the First Nations Health Plan, and the Transformative
Change Accord. The Council is tasked with advocating for the health priorities and
objectives o f Aboriginal populations in B.C.; administering the analysis of policy and
research in the health field; and contributing to the planning o f First Nations health related
policies and programming (First Nations Health Council, 2012).
The mental health needs of Aboriginal populations must be supported through
programming that acknowledges and serves to promote mental wellness through a balance of

13
the social, physical, spiritual, and emotional aspects of Aboriginal people. The First Nations
Health Council's recommendations for improving access and delivery o f mental health
services to Aboriginal populations reflect community feedback and encompass a broad
spectrum o f key areas. The community informed Council's recommendations include: the
need to include mental health services as a core element of First Nations community health
plans, health plans are to reflect community identified priorities; services must address the
contributing factors, including historical and social, that have had an impact on Aboriginal
mental health and substance misuse issues; detoxification services; supportive recovery; re­
entry; and life skill development. It is further asserted that programming must reflect the full
spectrum o f needs for both the individual and the community (First Nations Health Council,
2012 ).

Furthermore, community informed recommendations clearly identified two areas in
need of development that are central to the priorities of this project. The first of these
recommendations establishes the need for educational resources that support the
development o f cultural competency for professionals in the fields of mental and behavioural
health. Secondly, community informed recommendations identify the need for the delivery
o f integrated services that reflect both mainstream and traditional healing practices (First
Nations Health Council, 2012).
The information revealed through this review provides a helpful overview o f historical
and ongoing efforts by both settler and Aboriginal groups of interest, towards improving
access and delivery of mental and behavioural health supports for Aboriginal populations in
B.C. During my initial search o f the literature I was unable to find specific criteria for the
development of integrated approaches. Since then, a document known as A Path Forward:
BC First Nations and Aboriginal People's Mental Wellness and Substance Use -1 0 Year

14
Plan: A Provincial approach to Facilitate Regional and Local Planning Action. This
document hereby referred to as "The Plan" put forth a vision in which "All First Nations and
Aboriginal people in BC are supported in a manner that respects their customs, values, and
beliefs to achieve and maintain mental wellness and positive, healthy living regardless of
where they live" (First Nations Health Authority, 2013). The Plan's vision is supported by
the following goals:
• To improve services, supports, and health outcomes for all First Nations and
Aboriginal people in BC.
• To keep First Nations and Aboriginal people's well-being at the center of all
initiatives while maintaining a high operational standard, and cross-sectoral integration.
• To ensure that mental wellness and substance use strategies and actions for First
Nations and Aboriginal people reflect individual and family needs and are communitydriven and Nation-based.
• To engage First Nations and Aboriginal people in the journey towards improving
health outcomes.
In addition the Plan is inspired by the conceptual framework of the "Circle of
Wellness" which encompasses four quadrants, including: holistic wellness, community care,
integrated care, and specialized care (First Nations Health Authority, 2013). The Plan's
subsequent principles, direction, and actions are believed to provide a strong foundation from
which culturally-safe and relevant approaches to mental health service delivery may be
developed, supporting clinicians wishing to adopt integrated service approaches.

15

Research Considerations

Research considerations concerning Aboriginal populations have been the focus of
various scholarly inquiries on topics such as the decolonization of research methodologies
and reflections for a culturally relevant research framework (Jamieson et al, 2012; Smith,
1999). The following two book reviews are aimed at supporting the primary research query.
Linda Tuhiwai Smith's Decolonizing Methodologies: Research and Indigenous
Peoples (1999) offers a review of the historical occurrences and socio-political priorities that
have shaped the intent and outcomes of research endeavours on Indigenous populations. In
chapter 6, the author depicts the journey of Indigenous people across the world in furthering
their cause towards social, legal, and political equality. This journey sets the context for the
agenda on Indigenous research, otherwise known as the "Indigenous Peoples' Project" (p.
107). The Indigenous research agenda is represented through the "metaphor of ocean tides"
(p. 116), which depicts the views o f Indigenous peoples from the Pacific region and their
regard for the sea as a source of life. The metaphorically derived agenda presents four
"major tides" described as: survival, recovery, development, and self-determination (p. 116).
Ethical considerations in research practice include the struggle to overcome historically
derived Indigenous perceptions about the nature of research, as well as concerns about
Western views which govern influential factors that have a direct impact on the directives
and priorities for research (Smith, 1999).
The selected chapter offers a thought provoking review on the ongoing struggle of
Indigenous populations over the assertion of their rights, and in ensuring their voices are
heard and reflected throughout local and global priorities. The nature and impact of
colonization on the Indigenous communities of the world is considered from multiple
perspectives, including physical, spiritual, emotional, socio-economic, and political. The

16
author's examination of the ongoing impact of Western priorities on the welfare of
Indigenous populations is presented from a unique perspective that considers the
impediments these priorities place on the efforts of the global Indigenous community to
assert their rights and establish their agenda at the international level.
Another important aspect o f the author's contemplation is reflected in her approach to
taking both the historical and ongoing challenges faced by Indigenous populations around the
world and giving consideration to their impact on the Indigenous research agenda. The
provision of specific examples on Indigenous-based frameworks for research, offers
additional insight into the shaping of the Indigenous research agenda. Within the context of
the text, the chosen article provides a natural and helpful transition for the reader into gaining
a better understanding o f the unique journey Indigenous populations have taken towards
asserting their voice in academic and political circles.
The principles of best practice concerning research with Aboriginal populations are
described by Jamieson et al (2012) as an essential framework for conducting culturally
relevant inquiry. The principles are said to be reflected in a vast number o f scholarly
publications, as well as government entities. The authors set out to develop an accessible
document that would assist researchers in understanding and applying these principles. The
set of principles is divided into two categories, essential and desirable. Essential principles
are described as: addressing a priority health issue as determined by the community;
conducting research within a mutually respectful partnership framework; capacity building is
a key focus o f the research partnership, with sufficient budget to support this; flexibility in
study implementation while maintaining scientific rigour; respecting communities’ past and
present experience of research. Desirable principles include: recognizing the diversity o f
indigenous populations; ensuring extended timelines do not jeopardize projects; preparing for

17
indigenous leadership turnover; supporting community ownership; and developing systems
to facilitate partnership management in multicentre studies (Jamieson et al, 2012).
Aboriginal people are amongst the most studied populations in the world and research
with these groups has rarely been to their benefit (Smith, 1999). Moreover, historical
research conducted on Indigenous peoples was underlined with factors that were not ethically
sound, further perpetuating colonial power (Cochran et al., 2008). Researchers are tasked
with being cognizant o f the impact of historic research and being vigilant about these
sensitivities, while ensuring a balance of culture, purpose, and ethics. Furthermore, continued
pressure on the research community demands that organizational studies recognize the value
and importance o f efforts that are rooted in cultural awareness and safety, while embracing
the voice and expertise of Indigenous populations. Furthermore, the adoption o f culturally
relevant research approaches reflects the acknowledgment that the absence of Aboriginal
support and participation compromises the relevance and applicability of findings.
Jamieson et al’s (2012) contribution serves as an important advancement in
establishing clear guidelines for culturally relevant research. The authors’ stance may have
been further supported by the inclusion of examples on practical applications of research
endeavours guided by the recommended framework. Additional corroboration may have
been achieved through a scholarly analysis on the potential pitfalls of failing to apply the
recommended guidelines. Despite the noted shortcomings, the authors have effectively
succeeded in facilitating access to essential information that will assist in promoting ethically
based standards o f practice in research with Indigenous populations.

18

Aboriginal Mental Health

The history of Aboriginal people in Canada dates back thousands of years. Their
history speaks of a people wealthy in tradition with a strong sense of identity that derived
from their intrinsic connectedness with their environment. Complex social structures gave
individuals a distinct sense o f worth within the context of their community. They achieved a
sense o f balance and purpose through their connection with the environment (Aboriginal
Canada Portal, 2012). This ecological state of harmony would soon be disrupted by the
arrival o f a race that sought to impose their beliefs and values, while negating the intrinsic
strength o f the Aboriginal culture.
Colonization sought to promote a Eurocentric approach that strived to impose cultural
“progress” into well-established frameworks of socialization and identity. Conflicting
priorities resulting in the loss of vital social structures resulted in the loss of cultural identity
and vulnerability to insensitive dominant culture paradigms (Cannon & Sunseri, 2011, p. 9).
The period o f colonization in North America was a time o f great upheaval for the native
people o f Canada. The loss o f land and community resulted in isolation and vulnerability.
Recent acknowledgements on the impact o f this period in history have led to systemic
changes that seek to reinstate the rights of Aboriginal peoples in North America, while
recognizing their unique strengths and needs.
Mental health and substance abuse are a top concern for Canadian Aboriginal
populations (Ocampo, 2010). Aboriginal populations in British Columbia experience
significantly higher mental health or substance abuse problems when compared to the
population at large (National Aboriginal Health Organization, 2012). The significant
pervasiveness of mental and behavioural health issues amongst Aboriginal populations and
the lack of relevant standards for mental health practices, prompts a closer look at culturally

19
safe practices that are rooted in Indigenous paradigms. These approaches would serve to
address culturally-specific issues such as identity, trauma, colonization, traditional practices
that promote social and emotional well-being, skepticism, confidence-building, and advocacy
(Ocampo, 2010). Further concern arises when one considers scholastic assertions that the
application o f mainstream mental health frameworks of practice may serve to perpetuate the
cycle of traumatization for Aboriginal populations (Duran & Duran, 1995).
The concept o f Aboriginal mental health has been the focus of various scholarly
inquiries on topics such as Eurocentric consciousness, the basis for knowledge concerning
Aboriginal mental health, and multidisciplinary perspectives on Aboriginal mental health
(Graveline, 1998; Kirmayer & Valaskakis, 2009; Waldram, 2004). The following three
literature reviews are aimed at supporting the primary research query.
The impact of Eurocentric values and beliefs on the educational experiences of
Aboriginal populations in Canada is explored in Fyre Jean Graveline's Circle Works:
Transforming Eurocentric Consciousness (1998). Through an activist's stance, the author
challenges professionals o f all creeds and ethnicities to evaluate the origins of their practice
and consider the inherent value o f alternative ways of knowing and sharing knowledge. The
author explores Aboriginal teaching, feminist theory, anti-racist methodologies, and their
practical applications. In the section titled The Eastern Door: Challenging Eurocentric
Consciousness the author explores the notion of consciousness-raising. The origins and
modem conceptualization o f consciousness-raising are examined with consideration given to
the various applications of the concept, including that o f a feminist influenced approach.
Additional consideration is given to concepts of influence such as homogeneity and
heterogeneity. Particular attention is given to the impact of factors of oppression and racism
on the Aboriginal consciousness (Graveline, 1998).

20
The plight to promote the revitalization of traditional worldviews, while shedding light
on the impact and limitations of Eurocentric perspectives has resulted in notable
contributions by Aboriginal professionals and scholars, including Linda Tuhiwai Smith.
Smith (2001) examines the ongoing impact of Western priorities on the welfare of
Indigenous populations. Non-Aboriginal scholars have also contributed to this body of
knowledge (Ambtman, Hudson, Hartry, & Mackay-Chiddenton, 2010; Constantine & Sue,
2006; Fernando, 2003; Nebelkopf & Phillips, 2004; Regehr & Glancy, 2010; Waldram,
2004; Walker, Cromarty, Kelly, & St Pierre-Hansen, 2009), including the impact of
Eurocentric systems on research, service delivery, and access.
Graveline's commitment to implementing an Aboriginally-informed analytical lens
serves to shed light on the applicability and strengths found in traditional knowledge. The
reader is granted access to a well-informed comparison between mainstream ideologies and
traditional knowledge, allowing for an improved understanding on their similarities,
differences and conflicting priorities. The consistent referencing o f Aboriginal scholars
gives further credence to the value of the Aboriginal way of knowing. Another valuable
aspect of Graveline's (1998) stance is her ongoing encouragement of professionals to seek
knowledge beyond the restraints o f dominant paradigms. The professional community is
also challenged to examine its practice and its derived source o f knowledge in an effort to
detect and correct any racist-based approaches to practice.
James B. Waldram’s (2004) Revenge o f the Windigo: The Construction o f the Mind
and Mental Health o f North American Aboriginal Peoples seeks to address the basis for
knowledge concerning the mental health of Aboriginal populations. In Chapter 10 The
Clinician’s Aboriginal, the author examines the generalizations and misconceptions that have
served to shape the clinical conceptualization o f the Aboriginal client. From its

21
anthropological roots to its psychological origins, the notion of the Aboriginal client has been
shaped into a prescriptive configuration of value orientations, personality traits, and
characteristics of dysfunctionality. The generational transfer, within professional
communities, of misconceptions, and cultural biases is identified as a particular concerning
aspect of unquestioned ethnic and cultural generalization trends. The notion of homogeneity,
as it concerns Aboriginal populations, is said to have been challenged in recent years by
scholars who have come to acknowledge the diversity within Aboriginal groups. The impact
of socio-economic issues in shaping the value orientations of Aboriginal populations is
explored. The conflicting nature of literary resources and scientific knowledge concerning
the value orientation and cultural characteristics of Aboriginal populations is emphasized
with consideration given to its impact on culturally competent clinical practice approaches
(Waldram, 2004).
Cultural competency in clinical settings has been the focal point of a vast array of
scholarly efforts (Ambtman, Hudson, Hartry, & Mackay-Chiddenton, 2010; Nebelkopf &
Phillips, 2004; Walker, Cromarty, Kelly, & St Pierre-Hansen, 2009) concerned with
shedding light on the influences and implications of refined approaches to working with
multi-cultural populations. Waldram’s contribution provides an amply sourced and
insightful examination on the origins, influential factors, and implications of the clinical
conceptualization and work with Aboriginal clients. The author’s platform is strengthened
through his examination o f the factors, from both an anthropological and psychological
perspective, that have served to shape clinical approaches, deemed as culturally competent,
to working with Aboriginal clients.
Waldram’s (2004) straightforward analysis gives due consideration to the professional
implications of long-standing generalizations about Aboriginal culture. In challenging these

22
ill-informed and potentially dangerous generalities, the author prompts the professional
community to uphold well-informed, up-to-date standards of practice in the delivery of
culturally competent supports.
Overall, the author’s stance and recommendations are deemed as a valuable
contribution to the body of knowledge concerned with the conceptualization and delivery of
culturally competent supports and interventions. Despite the acknowledged contributions,
Waldram’s (2004) work may have benefited from a more inclusive and globally-minded
approach that considered similar trends of influence and response in other Western societies.
Consideration to the impact of noted historical influences from the perspective of similar
fields of practice would have further improved the applicability of the author’s position.
Kirmayer and Valaskakis’ (2009) compilation of multi-disciplinary perspectives on
Aboriginal mental health provides the reader with an opportunity to explore the various
social, economic, and political issues affecting the health and well-being o f Aboriginal
people in Canada. McCormick’s chapter on Aboriginal Approaches to Counselling (p. 337)
depicts innovations in counselling approaches to working with Aboriginal populations.
Factors influencing Aboriginal health and well-being are explored, including Aboriginal
worldviews, spirituality, tradition, and culture. The role of mainstream mental health
methodologies and traditional healing practices in supporting the mental health of Aboriginal
clients is also considered. The efficacy o f amalgamating mainstream and traditional
approaches is explored, giving consideration to applications within the context of multiple
counselling scenarios, including sex abuse, career/vocational, suicide, and substance abuse
(Kirmayer & Valaskakis, 2009)
The histories, worldviews, and needs of Aboriginal populations have prompted
acknowledgment from multiple areas of research and practice on the importance of

23
developing and implementing services that reflect the uniqueness of Aboriginal culture. The
development o f Aboriginally-relevant counselling methods is reflected in recent research
efforts, such as that of Limb and Hodge’s (2011) contemplation on the therapeutic
implementation of spiritual ecograms. Walker, Cromarty, Kelly, and St Pierre-Hansen
(2009) offer another recent example, within the Canadian context, of culturally competent
service delivery in addressing the health needs of Aboriginal populations.
The review of Aboriginal perspectives on well-being and healing presented as a helpful
introduction, granting the reader the opportunity to better understand the difference between
Aboriginal and mainstream perspectives on health and well-being. The comparative review
between traditional healing approaches and mainstream methodologies provided particular
insight into how integrated methods complement and strengthen the individual components,
while promoting improved client outcomes. The authors’ contemplation on the notion of
existentialism and its homogenous roots in both mainstream and traditional ideologies
concerning the search for meaning, grants the reader with an opportunity to consider not just
the differences, but the important similarities between the two belief systems.
McCormick (as cited in Kirmayer & Valaskakis, 2009, p. 337) succinctly captures the
essence o f what presents as a well-informed and conscientious journey towards culturally
competent practice. The chapter’s content also serves to validate the value of integrated
approaches to promoting the health and well-being of Aboriginal clients. The authors’
assertion that additional research is needed to further establish the value and impact o f both
traditional and mainstream approaches serves as a challenge to the professional community
to extend the body of knowledge in this area.

24

Mainstream Mental Health Approaches

The World Health Organization (WHO) defines mental health as the range of
endeavours aimed at promoting mental well-being, as related to overall physical, mental, and
social welfare. These endeavours include education, support, preventative measures,
treatment, and rehabilitation (World Health Organization [WHO], 2012). In the last century,
efforts to address mental illness have shifted in their approach. These shifts have undertaken
approaches that originally sought to isolate the individual facing a mental disorder, to
modalities that utilize social and environmental factors to promote prevention, treatment, and
care.
Mental health is further described as “a state of well-being in which the individual
realizes his or her own abilities, can work productively and fruitfully, and is able to make a
contribution to his or her community” (New Brunswick Department of Health, 2011, p. 2).
A lack of proper attention to one’s mental health may lead to compromised physical health
and productivity. The success of mental health interventions will greatly depend on the
professional’s ability to implement the appropriate combination of tools needed to meet the
unique needs of the client.
Mainstream mental health treatment approaches derive from consensus based
ideologies on what constitutes a problem and how the perceived problem may be addressed
through a cause and effect approach. The noted limitations with this type of “cookie cutter”
approach to service delivery are that it tends to rely on prescriptive categories or ideals, it
fails to give credence to internal experiences, it lacks appreciation for how individuals
respond to their environment, and it fails to account for cultural factors (Grobstein &
Cyckowski, 2006).

25
Mental and behavioural health services in northern B.C. are delivered through a variety
o f resources. These resources include government sponsored organizations and private
practice service providers. Government sponsored organizations responsible for the delivery
o f mental health services in northern B.C. include, the Northern Health Authority (NHA), the
Ministry o f Children and Family Development (MCFD), the Central Interior Native Health
Society, Friendship Centres, and federally funded health centres in reserve communities.
Service delivery through these organizations seeks to respond to age specific, cultural, and
lifespan needs o f northern populations.
The NHA provides mental and behavioural health services through a wide range o f
programming aimed at supporting individuals facing mental health or substance abuse issues

(Northern Health Authority, 2007). MCFD is specifically concerned with addressing the
mental health needs o f children and youth in B.C. Supports are delivered to children and
youth with mental health concerns and their families through a wide range of “communitybased specialized mental health services” (British Columbia, n.d.). The Central Interior
Native Health Society offers a Primary Health Care team approach in the delivery of
supports for Aboriginal populations in northern B.C. The organization is committed to a
holistic approach to health and well-being by addressing the four pillars of wellness:
spiritual, mental, emotional, and physical (Central Interior Native Health Society, n.d.).
The concept of mainstream mental health service delivery approaches has been the
focus of various scholarly inquiries on topics such as the facilitation of cultural competence
in mental health and educational settings, racist influences in mental health practice, cultural
relevance in family therapy, the impact of Western influenced tools in the delivery of mental
health services to diverse populations, and the implications of multiculturalism on the
helping profession (Constantine & Sue, 2006; Fernando, 2003; Marbley, 2011; McGoldrick,

26
Giordano, & Pearce, 1996; Regehr & Glancy, 2010). The following five literature reviews
are aimed at supporting the primary research query.
Constantine and Sue’s (2006) Addressing Racism: Facilitating Cultural Competence in
Mental Health and Educational Settings offers a compilation of scholarly works concerned
with exploring and analyzing issues of racism, as influenced by multiple factors such as
classism and poverty, and their impact on the quality and effectiveness of mental health
services. In Chapter 5 Linking Poverty, Classism, and Racism in Mental Health:
Overcoming Barriers to Multicultural Competency (p. 65), authors William Ming Liu, Jovan
Hernandez, Amina Mahmood, and Ren Stinson explore the root origins of socio-economic
and political factors and consider their impact on the access and perception of mental health
services by marginalized populations. The intersections of these oppressive factors are
deemed as important considerations to be included in the clinician’s repertoire o f personal
and professional developmental tools (Constantine & Sue, 2006)
The importance and impact of well-informed professional interventions presents as an
established platform in both professional and scholarly circles (Ambtman, Hudson, Hartry, &
Mackay-Chiddenton, 2010; Nebelkopf & Phillips, 2004; Waldram, 2004; Walker, Cromarty,
Kelly, & St Pierre-Hansen, 2009). Liu, Hernandez, Mahmood, and Stinson’s (2006)
contribution to Constantine and Sue’s text further emphasizes this platform through a
comprehensive examination of various oppressive factors and how understanding their
impact on marginalized populations can support culturally relevant practice in clinical and
education settings.
Liu, Hernandez, Mahmood, and Stinson’s (2006) scholarly contribution provides a
well-informed and insightful structural approach to culturally competent professional
development. Professionals are encouraged to consider their personal views concerning

27
racism, classism, and poverty, and how these may impact their practice. This challenge
invites reflection by professionals on how attitudes and policies may serve to perpetuate
racist trends. Additional merit is found in the inclusion of multicultural perspectives on the
noted factors o f oppression, including those o f African-American, Asian-American, NativeAmerican, and Latino populations. The inclusion of statistical data served to further
substantiate the authors’ stance and offered the reader a contextual perspective on the impact
o f racism, classism, and poverty.
Suman Fernando's (2003) Cultural Diversity, Mental Health and Psychiatry: The
Struggle Against Racism provides an examination of the racist influences impacting mental
health practice within culturally diverse populations. In Chapter 5 Moving Forward (p. 171)
the author delves into various factors, including legislative measures and professional field
initiatives, bearing impact on culturally relevant and anti-racist practices in the fields of
mental health and psychiatry. The roots of Western psychotherapy are explored in relation to
their impact on the "fundamental cultural assumptions" concerning the nature and condition
o f humanity (p. 197). The author reiterates the importance of acknowledging differing
worldviews and ensuring that this knowledge is reflected through constructive, wellinformed practice. The connection between the professional and the client is emphasized as
a key aspect o f effective therapeutic practice; consequently the value o f a well-informed
professional in matters concerning cultural views and values is accentuated. The author
further proposes changes to professional training that will better promote multi-cultural
perspectives and anti-racist practice (Fernando, 2003).
The limitations and implications of western derived perspectives on the
epistemological influences to the mental health field and their subsequent impact on mental
health practice, have served as a platform for scholarly efforts concerned with expanding and

28
improving our understanding o f these issues (Ambtman, Hudson, Hartry, & MackayChiddenton, 2010; Constantine & Sue, 2006; Nebelkopf & Phillips, 2004; Regehr & Glancy,
2010; Waldram, 2004; Walker, Cromarty, Kelly, & St Pierre-Hansen, 2009). Fernando's
(2003) contribution grants extensive focus on the issue of racism, its origins, its historical
impact, and its influence on the mental health field. The author's platform is further
enhanced through his assertions on the value of developing and implementing educational
approaches that foster multi-culturally informed, anti-racist, and culturally relevant
professional practice.
The most significant contribution to the body of knowledge is found in the author's
multi-level approach to developing and enhancing professional practice in the field of mental
health, as evidenced by the examination o f educational, cultural, geographic, societal,
economic, and political factors. Despite the value of these contributions, it is important to
note one important limitation, that o f the author's stance as predominantly influenced by
western worldviews, and its subsequent impact on the author's perspective and approach to
addressing issues of racism, multiculturalism, and culturally relevant professional practice.
The author's failure to acknowledge the impact of his own worldview limits the reliability
and applicability o f his ideas.
McGoldrick, Giordano, and Pearce’s (1996) Ethnicity and Family Therapy offers a
compilation o f works by various scholarly sources concerned with the expansion of
knowledge on the cultural relevance o f the family therapy model and applications of such a
model in multicultural environments. Chapter 2 offers Charles Etta T. Sutton and Mary
Anne Broken Nose’s contribution titled American Indian Families: An Overview (p. 31), in
which the authors explore the history and modem concerns of American Indian populations.
In addition the authors propose the implementation of the family therapy model as an

29
effective tool in addressing the unique needs of this ethnic group. The professional
community is reminded and encouraged to improve their understanding o f traditional
worldviews, cultural misconceptions, and stereotypes in order to advance the efficacy of
therapeutic supports and interventions (McGoldrick, Giordano, & Pearce, 1996).
The delivery o f well-informed and effective mental health services to culturally diverse
populations has been acknowledged by scholars and professionals alike, as a rapidly growing
reality for clinical staff (Marbley, 2011; Nebelkopf & Phillips, 2004; Oulanova, 2008;
Stevenson, 2011). Issues o f self-awareness, informed practice, culturally relevant practice,
and multiple approach integration are just some of the areas of interest scholars have
examined in an effort to improve our understanding and effectiveness in the delivery of
mental health services to multicultural populations. Sutton and Broken Nose’s (1996)
examination o f the similarities between a mainstream therapeutic approach and traditional
American Indian approaches to healing, serves to reiterate the applicability of traditional
approaches in multicultural settings.
The ongoing development of professional practice lies at the heart of Sutton and
Broken Nose's (1996) position. Furthermore, Sutton and Broken Nose (1996) solidified the
message that in understanding the worldviews of other cultures, the professional will be
better equipped to implement the most effective intervention approach and will be better able
to establish a respectful and empathetic therapeutic relationship. A comparative analysis on
the applicability o f other models of therapeutic intervention, such as group, art-based, and
outreach approaches, may have served to strengthen the authors’ platform. Information
concerning the authors’ background and professional experience would have served to
support the notion of positioning, a key aspect o f professional development.

30
Regehr and Glancy's Mental Health Social Work Practice in Canada (2010) offers a
comprehensive analysis of social work practice in a Canadian context. Chapter 4 Social
Work Assessment in Mental Health (p. 61) considers the impact of Western influenced
mental health evaluation tools in capturing an accurate depiction of the mental health status
o f diverse populations in Canada. The implementation of assessment tools within a cultural
context is explored with consideration given to the Aboriginal worldview, Asian perspective,
and African notions o f health. Socio-economic, political, and historical stressors on the
psychological health of the above noted ethnic groups are depicted. The varied range of
perceptions and manifestations o f psychological conditions as derived from culturally
influenced factors are examined. Emphasis is given to trends in expressions of distress that
lead certain ethnic groups to associated psychological unrest to physical symptomology.
Cultural influences on service access trends and culturally bound sets of symptoms are also
appraised (Regehr & Glancy, 2010).
Issues concerning multicultural access and perception of western culture influenced
mental health services have prompted scholarly efforts to shed light on the influential factors
and complexities associated with this area of concern (Ambtman, Hudson, Hartry, &
Mackay-Chiddenton, 2010; Constantine & Sue, 2006; Nebelkopf & Phillips, 2004; Waldram,
2004; Walker, Cromarty, Kelly, & St Pierre-Hansen, 2009). Regehr and Glancy (2010)
expand on this body o f knowledge through their well versed examination o f the efficacy of
mainstream mental health assessment tools, while exploring diverse cultural factors that may
impact the accuracy o f westernized means of measurement.
Regehr and Glancy's (2010) most significant contribution to the body o f knowledge is
found in their perceptive and clearly depicted overview of various cultural perspectives
concerning the origins and manifestations of mental health imbalances. Furthermore, the

31
authors’ platform is substantiated by their inclusion of statistical data concerning incidences
o f mental health diagnosis and treatment amongst some of the cultures that make up the
Canadian societal landscape. A closer examination of the most commonly used diagnostic
tools including the Diagnostic and Statistical Manual (DSM), grants the reader the
opportunity to consider the limitations within a multicultural context of commonly used
means o f measurement. It is important to note that the most recent version of this diagnostic
tool, the DSM-5, in a marked departure from previous versions, incorporates greater cultural
sensitivity and provides a broad array of information concerning cultural variances in
practice, including cultural formulation interview guidelines (American Psychiatric
Association, 2013). In contemplating the meaning of key concepts such as psychologization
and somatization the reader is granted the opportunity to consider the varied ways in which
psychological maladies may be conceptualized and experienced, giving further context to the
limitations of mainstream approaches.
Aretha Faye Marbley’s Multicultural Counseling: Perspectives from Counselors as
Clients o f Color (2011) provides an axiological study on multiculturalism and its
implications on the helping profession. In Chapter 1 From Hills and Molehills All Across
America (p. 3) the author explores the cultural landscape and history o f the United States
with an emphasis on issues of racism and acculturation, as it pertains to the delivery of
mental and behavioural health services. Service access and impact experiences of AfricanAmerican, Asian-American, Latino, and Native American populations are considered.
Furthermore, the author contends that professionals must become knowledgeable about the
history and unique cultural distinctions of their target populations in order to improve the
likelihood for effective interventions (Marbley, 2011).

32
Scholarly efforts to further our understanding on the impact o f multicultural factors in
the delivery o f therapeutic supports and interventions have continued to gain momentum in
recent years. Scholarly contributions such as those of Spanierman and Poteat (2005) in their
efforts towards promoting therapeutic frameworks and interventions that are informed
through multiculturally-minded research, have served to promote awareness about the
significance and value o f well-informed practice with culturally-diverse populations.
Marbley’s (2011) work provides a meaningful and valuable addition to these efforts by
capturing the voices o f professionals and service users in their experiences with delivering
and accessing culturally relevant supports and interventions.
The most valuable aspect of Marbley’s (2011) position is found in her assertion that
culturally relevant practice must be well-informed, requiring the professional to take an
active stance in his or her professional development. Another striking aspect of the author’s
approach lies in the source of the chapter’s title, which serves to remind the reader of the
fervent and violent nature of the nation’s ongoing journey towards multicultural integrity.
The inclusion of culture-specific examples, specifically concerning challenges in accessing
services and successful applications of culturally relevant interventions, grant applicability to
the concepts put forth. The definition of pivotal terms such as culture and race, lend further
credibility to the notion of well-informed practice. Despite the valuable ideas put forth by
the author, failure to consider the experiences and efforts of other nations presenting with
similar migration and diversity trends limits the poignancy of her message.

Traditional Aboriginal Healing Practices
Traditional Aboriginal healing practices have received a great deal of attention and are
now more commonly practiced due to recent protections, such as the Canadian Charter of

33
Rights and Freedoms, which ensure the freedom to explore and apply these methods.
Traditional ways o f healing include sweat lodges, smudging, talking circles, healing circles,
and Indian medicines (Henderson, 2008).
Traditional Aboriginal practices are rooted in the belief that balance and harmony with
nature must exist. Overall well-being is achieved through the balance of the four main
components o f human existence. Physical, emotional, mental, and spiritual aspects of the
self are deemed to be irrefutably interconnected. Some modem approaches to public health
and health promotion have adopted the Aboriginal ecological approach to well-being, giving
further credence to the value of these traditional approaches to health (Ministry of Health,
2007).
The notion o f traditional healing practices has been the focus of various scholarly
inquiries on topics such as the origin and role o f traditional healers, perspectives from Native
practitioners on the delivery o f supports to urban Aboriginal populations, and cultural safety
in the context of institutional change (Deloria Jr., 2006; Walker, Cromarty, Kelly, & St
Pierre-Hansen, 2009; Witko, 2006). The following three literature reviews are aimed at
supporting the primary research query.
The significance, role, and impact of traditional healers are examined through a series
of anecdotal accounts and reflective excerpts in Vine Deloria Jr.’s (2006) The World We
Used to Live In: Remembering the Powers o f the Medicine Men. In Chapter 1 of DreamsThe Approach o f the Sacred, (p. 1) the author explores the traditional healing approach to
deciphering dreams and using dreams as tools for healing. The origins, spiritual linkage, and
role o f medicine men are depicted. The experiences of traditional healers are illustrated
through anecdotal accounts. The significance of traditional events and the role these played

34
in supporting the holistic health of Aboriginal individuals and communities is described
(Deloria Jr., 2006).
The movement towards the revitalization of Aboriginal values, beliefs, and practices
has garnered significant support from scholarly circles, as exemplified by the works of Linda
Tuhiwai Smith (1999) and Fyre Jean Graveline (1998). Deloria (2006), a world renowned
Native American scholar, makes a significant contribution to this body of knowledge by
granting the reader access to traditional accounts and perspectives on the significant value of
traditional healing practices.
Deloria’s (2006) combined anecdotal and analytical approach grants the reader access
to traditional worldviews on health and healing, while considering the potential for modem
day applications. The author provides helpful insight as to the cultural implications
associated with the role o f traditional healers, including how the suppression o f these
practices has impacted the health and well-being o f Aboriginal populations. In exploring
traditional knowledge the author grants due recognition to the inherent wisdom of Aboriginal
holistic approaches to health. The author’s portrayal of the medicine man or traditional
healer, through anecdotal and first-hand accounts, offers great insight as to the qualities and
actions that constitute effective practice. These accounts attest to the importance of
continuing development in practice and the undeniable importance o f the therapeutic
relationship.
Witko’s (2006) book, Mental Health Care fo r Urban Indians: Clinical Insights from
Native Practitioners, offers a compilation o f works by various authors exploring culturally
relevant therapeutic approaches. In Part III, Section 7 of the text (p. 133) Dolores Subia
Bigfoot and Megan Dunlap explore the traditional origins of storytelling, its cultural
significance, and therapeutic applications. The use of storytelling as a therapeutic tool for

35
working with American Indian populations is considered through its applications in
supporting individuals facing histories of trauma, abuse, and neglect. Within an urban
context consideration is given to the use o f modem day technology, such as internet sites, in
order to gain access to traditional supports and tools. The authors also included sample
stories and application tools to further enhance the concepts presented (Witko, 2006).
The value and applicability of traditional healing ideologies and tools has gained
considerable attention in recent years, including the use of spiritual ecograms (Limb &
Hodge, 2011) and McCormick’s exploration on innovations in counselling approaches to
working with Aboriginal populations (Kirmayer & Valaskakis, 2009). Bigfoot and Dunlap
(as cited in Witko, 2006, p. 133) offer an exciting addition to this body of knowledge in their
exploration o f storytelling as a valid and helpful therapeutic tool.
By looking at the cultural significance and healing properties of storytelling
techniques, the authors have effectively given due acknowledgment to the value of
traditional ideologies and practices. The authors’ well laid out approach in exploring the
inherent developmental and therapeutic value of storytelling, beyond the context o f its
cultural significance within Indigenous populations, grants the reader the opportunity to
consider the application o f this valuable tool with various populations, regardless of ethnic
and cultural background. The inclusion of available resources, a variety of application tools,
including the use of mainstream clinical methods, and sample storytelling narratives served
to strengthen the applicability of the ideas presented. The usability of this technique in
different therapeutic settings, such as addictions treatment and sexual abuse therapy, granted
further validation as to the value o f storytelling as a therapeutic approach. Despite the
significant strengths o f this section, a more in-depth look at the value of integrated

36
mainstream and traditional approaches would have served to further substantiate the authors’
stance.
The chosen article describes the work of the Sioux Lookout Meno Ya Win Health
Centre (SLMHC) with First Nations populations of northern Ontario. Authorship of this
article reflects representation from the program’s leadership, including the organization’s
CEO and Special Advisor on First Nations Health. The authors explore the notion of cultural
safety and the process of affecting institutional change through the centre’s adopted model of
care. The historical and methodological origins o f the centre’s adopted modality, known as
the SLMHC menoyawin model, are also explored. A review of findings on the model’s
evaluation, provide the reader with an analytical perspective on the successes and challenges
o f delivering culturally safe services to the Aboriginal peoples of northern Ontario through
the centre’s Traditional Healing, Medicines, Foods and Support Programme (Walker,
Cromarty, Kelly, & St Pierre-Hansen, 2009).
Walker, Cromarty, Kelly, and St Pierre-Hansen’s (2009) article offers an in-depth
review on the conceptualization and application of culturally competent service delivery in
health care. Consideration for cultural competency through a cultural safety lens, grants the
reader an opportunity to consider the origins of culturally safe approaches to health care
practice. The authors’ exploration of the process of supporting both individual and
organizational transitions into culturally safe applications of service delivery is strengthened
by the inclusion of detailed information on the guidelines for cultural safety (Walker,
Cromarty, Kelly, & St Pierre-Hansen, 2009). Relevancy and clarity are enhanced through
the article’s depiction of institutional change, as considered through the experiences on the
development and implementation of the SLMHC Traditional Healing, Medicines, Foods and
Support Programme. Consideration for First Nations traditional healing views and practices

37
help to solidify the impact of the authors’ position. A review of the program’s expected
outcomes, obstacles to implementation, and results to date grant the reader an opportunity to
consider the realities o f implementing culturally safe health care programming for Aboriginal
populations.
Inclusion o f specific examples on other regional, national, and global approaches to
culturally safe health care practices, or mention of a lack of these, would have served to
further substantiate the article’s impact. Despite potential limitations in the authors’ stance,
the depiction o f a uniquely Canadian approach to culturally safe practices in the delivery of
health care services will serve to enrich the existing body of knowledge in this area. The
article also serves to provide an important perspective that may serve to inform future
endeavours looking to assess the delivery and impact of culturally safe approaches.

Integrated Mental Health Approaches
The integration o f traditional healing methods and mainstream strategies promotes
opportunities for health and well-being that are not bound by the scientific limitations of
western medical paradigms. A holistic view of health is adopted, allowing for the
acknowledgement and inclusion of the four pillars of health paradigm. This paradigm
considers human health from a perspective o f interconnectedness, as it includes the spiritual,
emotional, physical, and mental aspects of the self. These integrated approaches to health
also serve to promote empowerment, as well as a sense of connectedness with family,
community, and the environment (Henderson, 2008).
The notion of integrated approaches in the delivery of mental health supports has been
the focus of various scholarly inquiries on topics such as professional experiences on the
integration o f mainstream and traditional healing practices, the theoretical origins of Western

38
and traditional healing practices, approaches to promoting the mental health of Native
Americans, the application o f spiritual ecograms in promoting culturally relevant mental
health supports, culturally relevant mental health practice, organizational cultural
competency, the impact of traditional knowledge on the delivery o f professional supports,
cultural competency in the delivery of supports to minority and Aboriginal populations, and
culturally appropriate healing practices (Ambtman, Hudson, Hartry, & Mackay-Chiddenton,
2010; Bhandary, 2011; Carlick, 2009; Duran & Duran, 1995; Eshun & Gurung, 2009; Limb
& Hodge, 2011; Nebelkopf & Phillips, 2004; Oulanova, 2008; Sinclair, Hart, & Bruyere,
2009). The following nine literature reviews are aimed at supporting the primary research
query.
Olga Oulanova’s (2008) thesis project entitled Navigating Two Worlds: Experiences o f
Canadian Mental Health Professionals Who Integrate Aboriginal Traditional Healing
Practices considers the convergence of mainstream and traditional healing practices in the
field of mental health from the perspective o f mental health professionals in Canada. In
Chapter 4 (p. 97) the author embarks on an analysis and discussion concerning the study’s
findings. Findings reportedly revealed four central themes concerning professionals’
approach and experiences in implementing integrated methods of practice. Themes include:
Becoming the helper, deciding when to integrate, describing integrative efforts, and
experience with integration (Oulanova, 2008).
The delivery o f well-informed and effective mental health services to culturally diverse
populations has been acknowledged by scholars and professionals alike, as a rapidly growing
reality for clinical staff. Clinical perspectives on this issue have also gathered attention, as
exemplified by the works of Marbley (2011) and Stevenson (2011). Marbley’s efforts to
examine the perspectives of counselors as individuals and professionals of colour, offers a

39
unique outlook on the importance of self-positioning, as it relates to the professional’s ability
to understand how their personal cultural lens may impact their practice with diverse cultural
groups. Stevenson’s study offers a valuable account of Elder’s perspectives on the
integration of mainstream and traditional practices. Oulanova’s (2008) contribution takes the
clinician’s experience a step further by examining the various factors that influence
professional approaches to delivering culturally relevant supports and interventions.
Oulanova’s (2008) structural approach offers helpful insight on both internal and
external factors influencing the experiences and perspectives of Canadian professionals
delivering integrated mental health approaches. The journey towards becoming a helping
professional is described in terms of personal, historical, societal, and political experiences,
granting the reader an opportunity to consider the vastness of factors that help shape an
individual’s cultural lens.
Despite the valuable ideas put forth by the author, failure to consider the experiences of
non-Aboriginal professionals and their journey towards understanding and effectively
supporting Aboriginal populations, limits the poignancy of her message. The study’s scope
is also limited by the author’s failure to give due consideration to the experiences of
Aboriginal professionals working with populations of varying cultural and ethnic
backgrounds, including the benefits of traditional healing practices and integrative
approaches.
The theoretical origins of Western therapies and traditional healing practices or
“shamanism” are explored in Chapter 4, entitled Theoretical Concerns, of Duran and
Duran’s (1995) Native American Postcolonial psychology. A comparative analysis considers
both the similarities and differences between Western therapeutic strategies and roles and
those of traditional origin. The impact, positive and negative, of therapist and shaman roles

40
is explored. The integration of Western therapy approaches and traditional healing practices
is presented as a natural process that incorporates the long standing sources of knowledge
and modem adaptations of this knowledge, otherwise referred to as “collective psyche” (p.
66). The symbolism of the death and rebirth “transformative experience” (p.67) is presented
as an example o f the so-called collective psyche. Jung's four major functions of the psyche
tool is described and used to derive contrast between Western and Native American
worldviews. The application of this tool and a proposed variation that is described as more
accurately representative o f Native worldviews, are explored in their application in
therapeutic settings (Duran & Duran, 1995).
In exploring the parallel and contrasting origins of Western and Native worldviews and
subsequent therapeutic approaches, the authors have joined the ranks of various other
scholars (Kirmayer & Valaskakis, 2009; Limb & Hodge, 2011; Walker, Cromarty, Kelly, &
St Pierre-Hansen, 2009; Witko, 2006) in their pursuit to expand the body o f knowledge
concerned with improving our understanding of how these two perspectives may serve to
enhance clinical interventions and improve outcomes for Native clients.
Duran and Duran's (1995) comparison grants the reader an opportunity to consider the
congruencies between worldviews often considered as being at opposite ends of the
ideological spectrum. The analysis of the contrasting aspects of the two ideological
perspectives is presented in a manner that allows for critical consideration on the attributes
and potential applications of ideologically derived interventions. The concept of a collective
psyche supports the notion o f a common ideological foundation, which serves to grant
equality on the inherent value o f traditional practices. The comparison between the
paternalist quality o f Western views and the feministic nature of Native ideologies offers a
unique perspective on the historical and ongoing oppressive tendencies of one worldview

41
over the other. The use o f Jung's four major functions of the psyche tool offered additional
insight as to the limitations o f Western ideologies in granting credence and due honour to
differing worldviews that do not fit that schematic.
The authors' adherence to Jung's ideological teachings and methodologies limited their
scope's richness and impact on the value of their analysis. Consideration o f other notable
contributors to the Western repertoire of therapeutic methodologies would have served to
enhance the analysis of this culture's ideological trends. Equally limiting is the failure to
include the worldviews of other cultural groups, which may have served to broaden the scope
on the analysis o f ideological similarities and differences.
The realities o f developing and implementing culturally relevant programming are
explored in Nebelkopf and Phillips’ (2004) Healing and Mental Health fo r Native
Americans. Through their compilation of works, the editors have granted the reader an
opportunity to gain insight into the various approaches to conceptualizing, developing, and
delivering culturally relevant mental and behavioural services to Native American
populations in the United States. In chapter 15 HIV/AIDS Programs fo r American Indians
and Alaska Natives (p. 149) authors David D. Barney, Betty E. S. Duran, and Caitlin
Rosenthal, provide a detailed description and critical analysis on the work o f an agency
delivering HIV/AIDS supports to Native Americans in the San Francisco Bay area. The
authors deliver a detailed account o f the program, including funding sources and directives,
staff background and expertise, collaborative partnerships, and the integration of mainstream
and traditional approaches (Nebelkopf & Phillips, 2004).
The integration o f mainstream mental health methodologies and traditional Indigenous
practices has garnered significant attention from both professional and academic
communities (Duran, 2009; Kirmayer & Valaskakis, 2009; Limb & Hodge, 2011; Walker,

42
Cromarty, Kelly, & St Pierre-Hansen, 2009). This shift reflects an acknowledgment of the
inherent value o f traditional approaches while working with both Indigenous and mainstream
populations. The value and impact of multidisciplinary approaches is also gaining
momentum, as a reflection on the limitations of silo approaches.
Barney, Duran, and Rosenthal’s (as cited in Nebelkopf & Phillips, 2004, p. 149) review
and analysis provides a clear picture as to the origins, intent, and impact of the Native
American Health Center’s approach to working with HIV/AIDS at-risk populations. Their
work offers a meaningful insight into the process of envisioning, securing funding,
developing, and implementing culturally-relevant programming for Native American
populations. The analysis o f mainstream methodologies, deemed best suited for addressing
the needs o f Native American clients, grants due acknowledgement to the value of
frameworks for practice that reflect Indigenous ideologies.
The authors’ failure to give due consideration to regional, national, and international
efforts in the delivery of culturally relevant mental and behavioural health services, limits the
applicability of their work. Furthermore, the attention given to the vulnerabilities of bi­
sexual and gay populations may have served to foster misconceptions and fears about the
nature and risk of HIV/AIDS, despite wide acknowledgment by academic and professional
communities about the non-discriminating nature of the disease.
The selected article describes the scholarly views and findings of Limb and Hodge’s
(2011) research study on the application of spiritual ecograms for promoting cultural
competency in family therapy settings. The study in question contemplates the views of a
selective number o f Native American professionals, identified as having “extensive
experience” working with Native American populations, on the application of spiritual
ecograms within a therapeutic context. Furthermore, consideration is given to the tool’s

43
consistency with Native American culture and how it may serve to promote culturally
appropriate therapeutic interventions for Native American clients (Limb & Hodge, 2011).
The research project reflects increased recognition by the helping profession
concerning the importance of delivering culturally competent services to indigenous
populations. The focus o f this research project supports the development of cultural
competency at both the micro and macro levels, as exemplified in the work of Ambtman,
Hudson, Hartry, and Mackay-Chiddenton (2010). The development and application of
culturally competent tools appears to be gaining momentum (Walker, Cromarty, Kelly, & St
Pierre-Hansen, 2009), in recognition of the admitted limitations of mainstream approaches to
supporting indigenous populations (Limb & Hodge, 2011).
This shift towards recognizing and implementing culturally competent interventions
centers on the role o f spirituality within the context of individual and family well-being.
Admitted limitations in the availability and proven validity of spiritual assessment tools serve
as the driving force behind the project’s aim to assess the applicability and cultural
competency of spiritual ecograms. The tool’s origins, as depicted in terms of the
amalgamation o f traditional indigenous perspectives and mainstream professional tools,
serve to reiterate professional acknowledgement and interest in providing culturally
competent supports and interventions (Limb & Hodge, 2011).
Research findings provide a professional perspective, as represented by various helping
professions, on the similarities between spiritual ecograms and traditional indigenous
perspectives, as well as their applicability in the work of supporting indigenous families and
children. The inclusion o f various indigenous cultural voices, serves to further solidify the
project’s stance. Examples, term definitions, and considerations for clinical applications

44
provide the reader with a helpful overview on the origins and potential uses for spiritual
ecograms.
The project’s primary limitation lies in the use of a purposive/snowball sampling
strategy, which presents as a constraint in the project’s scope, through its limited
representation of participants, failing to capture broader professional perspectives, and
feedback from client populations. Failure to consider global perspectives and strategies
presents as an additional limitation in the project’s scope. Despite the admitted limitations of
the project, its findings and recommendations will serve to enrich the existing body of
knowledge in this area, while furthering the cause for culturally competent approaches in the
helping profession.
Eshun and Gurung’s (2009) Culture and Mental Health: Sociocultural Influences,
Theory, and Practice offers a compilation of scholarly works on the subject of a culturally
relevant mental health practice. Chapter 7 of the text, entitled Psychotherapy in a Culturally
Diverse World (p. 115), provides the reader access to Laura R. Johnson, Gilberte Bastien,
and Michael J. Hirschel’s contemplation on the ethical dilemma of operating from a
Eurocentric model o f care within the context o f a multicultural landscape. The authors
explore culturally sensitive practice options and examine available legislative and policy
directives on culturally relevant practice, including the DSM-IV cultural formulation tool and
the American Psychological Association guideline on multicultural approaches. Further
analysis reveals the pitfalls o f inappropriate approaches to cross-cultural interactions.
Consideration is also given to issues of racism and discrimination faced by ethnic minorities.
Additional consideration is given to the professional’s responsibility in developing culturally
competent practice through cultural awareness, knowledge, and skills (Eshun & Gurung,
2009).

45
Pressures within the helping profession to develop and deliver culturally competent
therapeutic services, have prompted extensive scholarly efforts to improve and expand our
understanding of the factors that are promoting this change and the impact of such
interventions (Ambtman, Hudson, Hartry, & Mackay-Chiddenton, 2010; Duran & Duran,
1995; Marbley, 2011; McGoldrick, Giordano, & Pearce, 1996; Nebelkopf & Phillips, 2004;
Oulanova, 2008; Stevenson, 2011). Johnson, Bastien, and Hirschel (as cited in Eshun &
Gurung, 2009, p. 115) consider this issue from the perspective of Eurocentric approaches,
their strengths and limitations, and how these compare to culturally accepted healing
practices.
Johnson, Bastien, and Hirschel’s (as cited in Eshun & Gurung, 2009, p. 115) stance is
well supported by their comprehensive analysis of Eurocentric approaches, including
detailed examples o f existing guidelines and professional enhancement tools, for delivering
therapeutic supports within the context o f a multicultural landscape. This position is further
enhanced by the authors’ comparative analysis on individualistic versus collectivist
worldviews. Another valuable aspect of this contribution is found in its overall tone, which
serves to encourage culturally relevant practice through well-informed professional
development. In addition, the inclusion of indigenous treatment examples further enhances
the comparative analysis between mainstream and traditional approaches.
The chosen article focuses on the improvement o f cultural competency for
organizations responsible for the delivery of services to Aboriginal populations. Ambtman,
Hudson, Hartry, and Mackay-Chiddenton (2010) depict the events and circumstances leading
up to the formation of a cross-cultural work group known as the Circle o f Courage. In their
article Promoting System-Wide Cultural Competence fo r Serving Aboriginal Families and
Children in a Midsized Canadian City (2010) the authors discuss how Dr. Martin

46
Brokenleg’s 1998 workshop on culturally appropriate Aboriginal youth interventions,
prompted organizers to consider how the ideas and methodology presented in the workshop
may be applied to affect long-term systemic changes. These considerations led to the
establishment of the Circle of Courage work group. Consideration is also given to literary
resources depicting approaches to supporting the development of cultural competence at the
micro, macro, and meta levels (Ambtman, Hudson, Hartry, & Mackay-Chiddenton, 2010).
The work o f the Circle of Courage group is explored, while giving consideration to the
frustrations encountered by professionals working in mainstream organizations. Identified
frustrations include the difference between dominant culture and Aboriginal culture
approaches to service delivery and interventions; and the challenges encountered while
attempting to implement culturally competent interventions. The group’s efforts are
reportedly guided by traditional Aboriginal values and reflect the group’s commitment to a
“concentric” approach, which focuses on micro level approach of supporting the individual
in developing cultural competency, which in turn promotes change at both the macro and
meta levels (Ambtman, Hudson, Hartry, & Mackay-Chiddenton, 2010).
The selected article provides the reader with a clear outline of the origins,
development, and progress o f the Circle of Courage work group. The literature review offers
a helpful framework that later serves to guide the reader through accounts of the group’s
efforts, as informed by the modalities identified in the review. The authors’ depiction of the
group’s approach to promoting cultural competency, grants the reader an opportunity to learn
about approaches to developing and promoting cultural competence within a Canadian
context.
Despite the above noted strengths, the article fails to provide a scholarly assessment of
how the efforts o f the Circle of Courage group compare to other approaches to promoting

47
cultural competence. The authors appear to have assumed a passive depiction of the events,
which fails to capture their personal stance and scholarly opinion. Their approach appears to
have limited the scope of their review to reflect the framework set out by the work group.
The article’s limited scope is initially made evident in the historical review, in which
the authors fail to provide the reader with information about Dr. Brokenleg’s background and
journey leading up to the inception of his workshop. Information concerning the workshop
in question is also limited, leaving the reader to wonder about the application of the model
beyond the scope o f the city o f interest. Updates on the current status of both presenter and
strategy are also lacking.
Another noted deficiency includes the scope of the literary review, which fails to
explore the root for the noted methodologies and address the existence or lack of alternative
approaches. The literary review is also limited in its consideration o f available tactics, while
focusing on mainstream methodologies and failing to include traditional approaches. A
comparative analysis between the group’s efforts and impact, and those of other entities
across the country, including global considerations, would have served to enrich the reader’s
experience.
Despite the outlined deficiencies, the article does succeed in capturing the unique
flavour of the Circle o f Courage’s approach to developing and promoting cultural
competency amongst educational and social service organizations. The depiction of a
uniquely Canadian approach to cultural competency will serve to enrich the existing body of
knowledge in this area. The article also serves to provide a launch pad for future endeavours
looking to assess the delivery and impact o f cultural competency approaches.
Sinclair, Hart, and Bruyere’s (2009) Wichitowin considers the historical and theoretical
underpinnings o f Indigenous social work. Practical application and traditional knowledge

48
are also explored. Bruyere’s Section III The Spirit o f Dreaming (p. 171) is concerned with
traditional knowledge and its impact on the delivery of social work supports and
interventions. The traditional conceptualization of the helper role is explored is this chapter.
The importance of self-positioning within a cultural context is emphasized, giving credence
to the value of self-awareness as the first stepping stone towards achieving cultural
competence. The role and impact of educational institutions and the programs they offer is
considered and determined to be a crucial component in the journey towards achieving
cultural sensitivity and relevance in social work practice (Sinclair, Hart, & Bruyere, 2009).
In recent years scholarly voices have placed significant emphasis on the value of
culturally relevant multi-disciplinary service delivery (Duran, 2009; Kirmayer & Valaskakis,
2009; Limb & Hodge, 2011; Walker, Cromarty, Kelly, & St Pierre-Hansen, 2009;).
Culturally relevant practice continues to evolve, as exemplified by counselling approaches
that mirror traditional knowledge and practice, and the application of intervention tools that
incorporate both mainstream and traditional methodologies. The importance o f affecting
change at various levels o f influence, including micro, macro, and mezzo is also
substantiated by professional and scholarly sources.
Bruyere’s (as cited in Sinclair, Hart, & Bruyere, 2009, p. 171) platform is strengthened
through the recognition o f modem multi-disciplinary contributors to the plight o f culturally
relevant Indigenous practice. Furthermore, by exploring the helper’s cultural positioning, the
author effectively prompts the reader to consider his or her cultural landscape and how it
may impact his or her practice. The road towards cultural relevance is further enhanced by
the author’s examination of the significance of language and how the helper’s role may be
enhanced through an improved understanding of idiomatic concepts and applications
(Sinclair, Hart, & Bruyere, 2009).

49
The author’s choice to reflect and build upon his background and knowledge of a
specific Aboriginal culture, in this case that of the Nishnawbe-Aski Nation, limits the
applicability of his work. Failing to explore the richness of the numerous Indigenous cultural
perspectives in Canada deprives the reader of an important reminder that all Indigenous
cultures are unique and that a single strategy to working with these populations will fail to
capture the distinctive flavour of each community’s traditions, language, and world views.
Kulraj Bhandary’s (2011) practicum report entitled Cultural Competency: A Path to
Deliver Healthcare to Ethnic Minority and Aboriginal Populations provides an analysis of
the realities of implementing cross-cultural competency approaches to service delivery in a
hospital setting. The author describes his practicum placement experiences in working with
clients from various ethnic and cultural backgrounds, primarily Aboriginal and East Indian,
accessing services at University Hospital of Northern B.C. (UHNBC) in Prince George. The
challenges of accessing culturally sensitive resources are explored. The author’s personal
journey in developing his own approach to culturally competent practice, presents as the
primary focus o f the report. Systemic challenges in the delivery of culturally competent
services to multi-cultural populations are considered from the author’s perspective as an
incoming health care professional (Bhandary, 2011).
The development and implementation o f culturally competent supports and
interventions in health care has in recent years received considerable attention, as
exemplified by the works of Walker, Cromarty, Kelly, and St Pierre-Hansen (2009) and
Nebelkopf and Phillips (2004). Walker, Cromarty, Kelly, and St Pierre-Hansen consider
cultural competency through a cultural safety lens and explore the origins of culturally safe
approaches to health care practice. The authors further the scope of their research by
considering the process o f supporting both individual and organizational transitions into

50
culturally safe applications of service delivery. Nebelkopf and Phillips’ compilation of
works offer an opportunity to gain insight into the various approaches to conceptualizing,
developing, and delivering culturally relevant health services to Native American
populations in the United States.
Bhandary’s (2011) first-hand account about the experiences of an emerging
professional in the field o f health care faced with the challenges of understanding the needs
of culturally diverse populations, presents as the most valuable aspect of his report. Further
to this contribution is the valuable insight offered through the author’s reflection on his
personal journey towards cultural competency and how the experiences of his practicum
placement served to shape his approach to working with culturally diverse populations.
Limitations concerning Bhandary's (2011) report include generalizations concerning
the application of traditional healing practices, such as the medicine wheel, which
compromise the applicability o f ideas. Furthermore, content relevance is restricted by a
failure to substantiate proposed ideas with relevant statistical or scholastic data.
Melissa Carlick’s thesis report entitled Yukon First Nations Youth Mental Wellness:
The Development o f Culturally Appropriate Healing (2009) considers modem mental health
approaches versus traditional healing practices and their impact on the well-being of
Indigenous populations. In Chapter 3 Strengthening Mental Wellness, the author explores
the efforts of a Northern BC initiative known as the Initiating Change Project (ICG). The
project’s primary focus is described as working towards promoting community wellness and
sustainability through the integration of mainstream and traditional practices. The revival of
traditional systems is identified as a key aspect of the project’s efforts. The sustainment of
traditional ways o f life is depicted as an essential aspect of promoting self-esteem, respect,
balance, connectedness, and healing amongst Aboriginal populations. The project reportedly

assumed a number o f tasks, fifty seven in total, meant to support the identified goals. Tasks
included efforts to promote community inclusiveness, the construction o f a traditional
spiritual house, the development o f cultural camps, the renewal of traditional rites of passage,
and the creation o f a traditional Sweat Lodge (Carlick, 2009).
The limitations of mainstream mental health approaches in meeting the needs of
Aboriginal populations have been the source of much debate and controversy amongst
scholarly and professional communities (Ambtman, Hudson, Hartry, & Mackay-Chiddenton,
2010; Duran & Duran, 1995; Eshun & Gurung, 2009; Marbley, 2011; McGoldrick,
Giordano, & Pearce, 1996; Nebelkopf & Phillips, 2004; Oulanova, 2008; Stevenson, 2011).
Carlick’s contribution to these scholarly debates offers important insight into modem day
efforts to revamp existing health and social service systems in order to meet the unique needs
of Aboriginal populations. Carlick’s example delivers practical insight into the realities of
integrating traditional healing practices and mainstream systems.
Carlick’s (2009) assessment of a multi-level approach to improving cultural
competency in the delivery of mental health services grants the reader the opportunity to
consider the realities of implementing change at the micro, mezzo, and macro levels of
programming. This approach takes the reader beyond the theoretical notions of cultural
relevance, providing a unique opportunity to gain a better understanding of traditional
systems and practices, and how these may serve to supplant or complement mainstream
approaches. Limitations are found in the author’s failure to consider other projects and
initiatives at the local, regional, national, and global levels. This comparative analysis may
have served to strengthen or weaken the sample project’s stance and approach, which focuses
on the sociocultural needs o f specific Aboriginal groups, thus limiting the applicability of the
project’s findings. This perceived shortcoming presents as a potential advantage to the

52
reader, as it may serve to incite awareness about the cultural variances found amongst
Aboriginal populations.
Charles Waldegrave's (2009) Cultural, Gender, and Socioeconomic Contexts in
Therapeutic and Social Policy Work contemplates cultural, gender, and socioeconomic
equity issues as they relate to matters concerning social inclusion and well-being and how
these may impact effective therapeutic interventions, research endeavours and policy
making. The contextual implications of culturally, gendered, and socioeconomic derived
designations o f meaning as they relate to the individual's sense of identity and self-worth are
considered. Waldegrave examines the limitations of policies and programming derived for
universal stereotypes, which often reflect western contextual assignments of meaning, such
as individualism. These universal stereotypes contradict non-western social standards such
as collective notions o f wellness, consequently impacting the effectiveness and cultural
relevance o f policies and programming that this self-ascribed "universal wisdom".
Waldegrave goes on to assert that "it would be even more enlightening if high-quality nonWestem approaches were given consideration when addressing some of our enduring social
problems" (p. 89).
New Zealand's Family Group Conferencing model (FGC) is presented as a
meaningful example of a non-western approach derived from Maori collective notions of
wellness. FGC is described as a non-adversarial model of practice that aims to strengthen
and empower families facing welfare and justice problems and is a globally accepted model
o f practice. Waldegrave (2009) captures the essence of this message by stating that "when
people’s cultures are honored, their sense of belonging is also honored and that enhances
their experience of well-being" (p. 98). Waldegrave also examines issues concerning gender
and socioeconomic equity and goes on to explore the potential role helping professionals

53
may have in impacting policies and programming, so they may reflect the realities of the
populations they serve.
Waldegrave's (2009) article offers an interesting perspective on the impact of
western-derived cultural, gender, and socioeconomic factors on policies and programming
affecting vulnerable populations. This perspective challenges one-size fits all approaches
that seek to conform diverse standards and perspectives on safety and well-being to those
established by the dominant culture. Waldegrave's challenge to helping professionals
provides fertile ground for discussion about the role of professionals in ensuring that the
policies and programs they represent are in the best interest of the individuals, families, and
communities they serve.

Considerations for Rural Practice
Populations residing in rural and remote communities in Canada are faced with unique
challenges that have a direct impact on their mental well-being. These challenges are related
to issues o f isolation, colonization, trauma, and socio-economic considerations. Restricted
access to services due to geographic isolation and socio-economic issues translates into the
over-taxation of existing resources, including formal and informal mental health supports
(O’Neill, 2009). Aboriginal Communities in northern B.C. are faced with many of these
challenges.
Considerations for the delivery o f mental health supports in rural geographical areas
has been the focus o f various scholarly inquiries on topics such as outreach service
modalities and challenges in the delivery of mental health supports to rural communities
(Sawyer, Gale, & Lambert, 2006; Sherman, Pong, & Swenson, 2010). The following two
literature reviews are aimed at supporting the primary research query.

54
The delivery o f services in rural communities presents a unique set of challenges. The
assertion is made that multiple models of practice are needed to reflect the varying needs and
capacities within rural communities. The outreach model is presented as a viable option for
supporting rural practice. This model of practice has experienced adaptations and variations
in order to support community needs and provider preferences. The original model reflects
the hospital and community mental health centre secondary level outreach modality, a wellestablished health care service delivery framework (Sherman, Pong, & Swenson, 2010).
The original outreach model offered limited primary care provider interaction, with
interventions occurring at the community mental health worker level. Community mental
health providers are typically responsible for coordinating care and service integration with
primary care physicians and other care providers. Outreach services offer some level of care,
but tend to leave the ongoing care to community-based providers. Limited face-to-face
contact prompts the delivery of outreach supports via alternative means, such as telephone or
e-mail. Outreach services may also include limited education services. Professional derived
recommendations suggest improvement on the delivery of outreach services that include an
increase in face-to-face support, increased capacity for formalized educational and capacitybuilding opportunities (Sherman, Pong, & Swenson, 2010).
The challenges associated with the delivery of mental health services in rural
communities present similar themes across literary resources. These themes include the lack
of available professionals and the strain this places on rural residents in need of services.
Furthermore, urban models o f care fail to account for the unique circumstances of rural
communities. These challenges are exacerbated through national and local policies that
continue to operate on misconceived perceptions of rural realities (Sawyer, Gale, & Lambert,
2006).

55
Despite the need for improved programming in rural areas, the majority of mental and
behavioural health programs exhibit under-resourcing when compared to their urban
counterparts. Quite frequently, rural mental and behavioural health services are office-based
practices located in moderately sized towns that see people on a one-to-one basis for
outpatient sessions. The most significant challenge in improving the delivery of mental
health services for rural communities does not reflect common source barriers, such as
funding or training, but instead reflects a failure by the rural mental health community to
develop and advocate for innovative solutions to practice that reflect the unique needs of
rural communities (Sawyer, Gale, & Lambert, 2006).

Summary
This literature review has included an overview o f some of the challenges and benefits
o f integrating traditional Aboriginal healing approaches into mainstream mental health
practices. The role and impact of historical, as well as ongoing socioeconomic and political
challenges, on the Indigenous research agenda were also considered. Additional
contemplation is given to the importance of establishing ethically based standards of practice
in research with Indigenous populations. Considerations concerning research standards and
practices were deemed to be o f importance as these efforts have a direct impact on systems
o f practice.
Reflection on the conceptualization of Aboriginal mental health and the factors
influencing the mental wellness of Aboriginal populations were also included in the scope of
this review. Data on the impact of the Eurocentric consciousness on the mental wellness of
the Aboriginal psyche offered a valuable opportunity to consider the impact of Western
influences on traditional standards of health and well-being. Further insight was provided

56
through the analysis of multidisciplinary perspectives on Aboriginal mental health. Western
influenced perspectives on the nature and factors influencing Aboriginal mental health seem
to clash when compared to Aboriginal perspectives on the issue.
The integration o f mainstream and traditional approaches to mental health is
considered from a multitude o f perspectives, including professional experiences, theoretical
origins, approaches to promoting Aboriginal mental health, the use of traditional tools for
healing, cultural relevance in practice, organizational competency, and traditional
knowledge. Traditional healing is explored by scholars from various standpoints, including
the origins of traditional healing, roles within traditional healing, Native professional
perspectives, and culturally safe organizational shifts.

57

Chapter Three: Theoretical Orientation and Methodology
In chapter three I will examine my research approach and ethical concerns, as well as
identify the population scope, and outline the research procedures, including the process for
data analysis and evaluation. The process of selecting an approach for my research was
informed by a framework o f action that prompted careful consideration o f philosophical
assumptions, strategies o f inquiry, and methodology for each o f the research approaches
being considered (Creswell, 2003). I selected a qualitative approach, guided by
constructivist assumptions, and supported by the application of a descriptive research
strategy. I adopted a Thematic Analysis approach to examine the research data. I selected
this research approach because I believed that it was the most appropriate in its design to
support the identified objectives and focal query of my research. A more in-depth look at the
components o f this research approach will serve to further substantiate this choice. From the
perspective of a novice researcher I believe that a qualitative approach offered the tools
needed to capture the voices and experiences of the clinicians delivering integrated mental
health strategies.
My research was informed by the theoretical underpinnings of qualitative inquiry.
Qualitative research is described as a strategical approach to social inquiry that seeks to
interpret social phenomena as guided by the target population’s assigned meaning. The
focus o f qualitative inquiry is to generate, rather than test theoretical knowledge (Bryman,
2008). Qualitative research challenges the notion of social phenomena as replicable and
distinct, and regards it as unique and reflective. Social processes are a key area of interest
for qualitative inquiry (Van Maanen, 1983). I selected a qualitative research approach
because it supports my project's intent to interpret the target population's experiences and
perspectives on the research topic. A qualitative approach also supported my goal to capture

58
details about the complex experiences of my target population while preserving the meanings
individuals attributed to their unique experiences.
The constructivist knowledge claim asserts that an individual’s search for
understanding will result in the assignment of subjective meaning to their experiences.
Through a constructivist lens, I sought to understand the situation as perceived by the
participant and as influenced by social and historical factors. Data gathering tools provided
broad direction that allowed the participants to conceptualize their assigned meaning of the
situation, as supported by the constructivist approach. This approach is concerned with
contextual factors and processes o f interaction amongst individuals (Creswell, 2003).
Constructivism assumes that individuals construct meanings as part o f their engagement with
the world they seek to interpret (Creswell, 2003). These interpretations are influenced by the
individual's "historical and social perspective" (Creswell, 2003, p. 9).
The descriptive research approach seeks to describe a phenomenon through a systemic
and precise approach to data gathering (Singleton & Bruce, 2005). Through a descriptive
approach I was able to describe, record, and report the experiences of participants, while
illustrating their unique characteristics (Marlow, 2011). This approach supported rich
descriptions that emerged from a carefully selected participant pool (Marlow, 2011).

Research Question
A good research question is meant to define the investigation, set boundaries, and
provide direction. The process of developing the research question is one that is iterative in
nature and should be informed by ideas, literary resources, and methodologies (O’Leary,
2004). In developing the research question, I sought to ensure that its scope was not too
broad or narrow, as either may impact the overall quality and usefulness of the research

59
findings. With this framework in mind, I gave careful consideration to the formulation of the
research question in ensuring that it captures the intent of the project. The research question
addressed in this project was: What are the challenges and benefits to integrating traditional
Aboriginal healing practices and mainstream mental health approaches? The research
question was supported and enhanced through the implementation of semi-structured
questions. The interview questions guided the process of describing the experiences of
clinicians implementing integrated strategies in northern B.C. Please refer to Appendix C for
a complete listing of the research interview questions.

Research Population and Sampling

I applied a convenience purposive sampling strategy in the selection of participants.
The convenience, sampling approach is reflected in the selection of a sample population that
was accessible to me. I chose the purposive sampling strategy because o f its strategic
qualities, which support the selection of participants that are relevant to the research focus
(Bryman, 2008).
The sample population was comprised of child and youth mental health clinicians who
have practiced in the northern region of British Columbia within the last two years. All
participants were employed by the Ministry of Children and Family Development at the time
the data was gathered. Participants had a minimum of two years’ experience practicing in
the geographic area of interest. This sample included both Aboriginal and non-Aboriginal
professionals with experience in the field of mental health that ranged from five years to up
to twenty seven years. Participant caseloads were representative of significantly high
numbers of mandated clients, with some caseloads reflecting a very small number of
voluntary clients. The sample size I hoped to achieve was a minimum of four and maximum

60
of six participants, with circumstances such as level of response and respondent suitability
resulting in a total o f four participants. The research sample was comprised of one male and
three female participants, including one participant who self-identified as Aboriginal, another
who self-identified as Southeast Asian, and two participants who self-identified as
Caucasian. The research sample was identified through Microsoft Outlook address book
listings o f Child and Youth Mental Health workers in the North Central, Northeast, and
Northwest Service Delivery Areas. Access to this information required Ministry approval
and is included as part o f the Ministry’s ethics approval process.
A total o f five clinicians were interviewed, but the decision was made to remove the
data gathered from one participant due to the participant’s confusion around the intended
meaning concerning integrated approaches and a lack of experience in delivering such
methods. The data gathered from the four remaining participants interviewed offered a
wealth of information on the application o f integrated approaches in Northern B.C.,
including personal and professional perspectives on the realities of incorporating innovative,
culturally relevant interventions and supports.

Ethical Concerns
In my research I sought to gather and describe information concerning the perspectives
o f child and youth mental health clinicians on the integration of mainstream mental health
approaches and traditional healing practices. In the context of my research, I sought to
conduct research that respected the confidentiality of the participants and ensured adequate
safeguards to protect the integrity of the research process.
All research participation was voluntary. Participants were provided with a description
of the proposed research project, the rationale for the research, and the requirements for their

61
participation. Participants were provided with informed consent information. Copies o f both
the information letter and accompanying consent form have been provided as part o f this
document and can be found in Appendixes A and B. The consent outlines the research focus,
as well as the participant’s rights, risks, and benefits (Bryman, 2008). Consents were
electronically signed prior to participation. Participants were advised of their right to
withdraw from the research at any point, without consequence. All signed consent forms
were kept in a secured location.
Research approval was obtained from the University o f Northern British Columbia
Research Ethics Board (REB) prior to the commencement of my research. Given that the
participants were staff of the Ministry of Children and Family Development, additional
ethics approval was requested and obtained from the designated Ministry representative.
The challenge o f ensuring confidentiality and anonymity while performing qualitative
forms of analysis requires transparency in all communications and information provided to
participants. Efforts were made to address these concerns through the production of
anonymized transcriptions, through the assignment of pseudonyms as identifiers for each
participant (Gibbs, 2007). Furthermore, no identifying information is contained in the final
research document. I handled and completed all transcriptions of the interview recordings.
I applied the process of reflexivity, as prompted by the tenets of qualitative research, to
support self-reflection and examination on how personal background, experiences, and views
may influence the research (Van Den Hoonaard, 2012). The use of personal journals
supported self-observation through a "stream-of-consciousness" data collection approach
(Marlow, 2011, p. 175). I used journaling as a tool for tracking research progress and
identifying existing or potential barriers. I completed a journal posting after each interview

62
to further support self-reflection about my role and its impact on the research process
(Marlow, 2011).
In order to ensure ethically sound conduct within the context o f this research,
consideration was given to my role as both researcher and representative of the organization
from which the research sample was selected. I applied a process of journaling to support a
clear and accountable research process, in an effort to acknowledge Ministry support of this
research and my dual role as researcher and Ministry employee. Standards of conduct within
research strive to “avoid deceit, exploitation, abuse or other forms of malpractice” (Carey,
2012, p. 97) and include such guidelines as non-malevolence and dignity, access, respect,
avoiding discrimination, voluntary participation, informed consent, data collection,
confidentiality and anonymity (Carey, 2012, p. 100-102).
For the purposes o f my research special consideration was given to transparency and
safety of participants through the application of the following rules of conduct: access,
voluntary participation, informed consent, data collection, confidentiality, and anonymity.
An information letter and consent form was made available to all participants via e-mail and
prior to any data collection. Participants were instructed to provide their consent by
responding to the original e-mail. These documents outlined the role of the researcher,
inclusive o f both organizational ties and academic focus; the voluntary nature of participation
in the research; methods for data collection, including data storage; and processes for
supporting confidentiality and anonymity, including the methods for data collection and the
handling of transcripts. In addition and in an effort to further acknowledge the potential
impact of my dual role within the context of my research, I took steps to make the
“participants’ interests primary” (Grinnell & Unrau, 2005, p.41), by remaining alert about
my dual role and maintaining ongoing transparency with all participants.

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Data Collection

An example o f a descriptive research data collection strategy is that o f the interview
approach. The interview approach is described as a means to “extract data that already exists
inside the individual” (Van Den Hoonaard, 2012, p. 81). Interviews are further described as
a method that incites participant recollection and reflection. This process is believed to
promote the formulation o f ideas and opinions, while supporting the exchange and possible
creation of information (Van Den Hoonaard, 2012). This technique allows for greater
flexibility to make adjustments in order to accommodate the participant’s needs. The
interview approach also offers improved opportunity for appraising the validity of the data
gathered, by providing an opportunity to observe the context in which responses are
provided. In the interview situation, the flexibility exists to accommodate the social
atmosphere, providing a more suitable environment for the disclosure of emotionally laden
topics (Platt, 2001). The above noted qualities supported my decision to adopt the interview
approach as the primary data gathering tool.
For the purposes o f my research, the interview approach was adapted to occur via
telephone. Face-to-face interviews were initially considered, but schedule limitations
presented as a challenge to my ability to travel to remote and rural communities in order to
meet participants. After careful consideration, I decided that phone interviews would allow
for the type o f flexibility need to accommodate both my schedule limitations and the
scheduling needs o f participants. I e-mailed the interview questions to participants via a
secured internal communication system, 48 hours prior to the scheduled interview in order to
allow for sufficient time for participants to review the questions, consider their responses,
and communicate any concerns. Prior to initiating each interview I asked participants if they
had any questions or concerns about the process as described in the information letter.

64
Participants were also reminded that a gift card was available and that mailing information
would be collected after the interview. Interviews were recorded for later transcription
(Bryman, 2008). I applied a semi-structured interview process, in the form of open-ended
questions. The semi-structured interview process allowed for an intuitive and free-flowing
collection of data (Marlow, 2011). I believe that this approach granted participants the
opportunity to formulate and particularize their own answers. All participants were later
provided with a copy of their interview transcripts to support the credibility of the process
(Van Den Hoonaard, 2012).
While conducting interviews, I found that the use of open-ended questions through a
semi-structured interview process created a space that allowed for the natural flow o f
conversation and the richness of storytelling. These stories provided me with an opportunity
to understand the experiences that have shaped each individual participant’s practice,
including the decision that prompted the use of integrated approaches and unique delivery of
such techniques.

Data Analysis
The research findings were analyzed via a Thematic Analysis (TA) approach and
guided by an inductive process, as previously described in Chapter Three. This process was
guided by Marlow’s five dimensions of qualitative analysis, including preparation, content
analysis, category identification, data validation, inscription, and interpretation (Marlow,
2011). Data analysis was further enhanced by Braun and Clarke’s (2006) measures for
supporting the integrity o f this process through data familiarization, code engendering, theme
search, theme review, theme definition, and labeling.

65
I began the process o f analyzing the findings from my research by transcribing the
recordings from the selected interviews. This process assisted me in becoming more familiar
with the data, granting an opportunity to give in-depth consideration to participant responses
and reoccurring themes. As part o f the process and in acknowledgement of the value of
reflexive practice I documented any ideas or questions that arose, which served to support
me in understanding how I arrived at the final analysis of the data. After completing all the
second level coding o f the data, I then began to analyze it. Structural themes, as informed by
various categories emerged (See Figure 1). All coding and analysis was completed manually
and quotes were used to support my findings.
Thematic Analysis (TA) is described as a “descriptive presentation of qualitative data”
(Anderson, 2007, p. 9). TA supports the depiction of themes, as identified within the
research data. TA is believed to provide a critically subjective approach to the examination
o f data (Anderson, 2007). In TA observation is said to precede understanding, recognition is
said to precede encoding, which in turn precedes interpretation (Boyatzis, 1998).
Furthermore, thematic analysis offers an adaptable method for recognizing, studying, and
exposing patterns contained in the data. I chose a theoretical thematic analysis approach in
order to support the coding of the research data (Braun & Clarke, 2006).
The analysis o f the research data was guided by the dimensions o f qualitative analysis,
as noted by Marlow (2011). These five dimensions of analysis include: preparation; category
identification; data validation; inscription; and interpretation. Within the scope of thematic
analysis, additional steps were taken to ensure the integrity of the process. The steps or
phases, as depicted by Braun and Clarke (2006) include: data familiarization; code
engendering; theme search; theme review; theme definition and labeling; and the creation of
the report.

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Concern for ensuring the validity of the research findings prompted a closer look at the
concepts and processes designed to support this priority. Reliability in qualitative research is
supported through the implementation o f methods for collecting and analyzing data that are
deemed legitimate by the research community. In terms of ensuring the validity o f the
research findings, processes must support the original intent of the research endeavour,
meaning that the project must achieve what it sets out to do (Collingridge & Gantt, 2008). In
the interview situation, the flexibility exists to accommodate the social atmosphere,
providing a more suitable environment for the disclosure of emotionally laden topics.
Furthermore, I believe that the adoption and competent application of reliable qualitative
methods served to ensure both the reliability and validity of the research findings.
In analyzing my research data I applied Marlow’s (2011) dimensions of qualitative
analysis:
1. Planning and organizing the data.
2. Identifying categories within the data, through an inductive approach that allows
for “patterns to emerge from the data rather than being developed prior to
collection” (p. 217).
3. Interpreting the findings through the use of cluster diagrams.
4. Validating the data by giving consideration to “alternative hypotheses, negative
cases, triangulation” (p. 225), preserving the contextual value of the data, and
establishing personal credibility.
5. Writing it up. As part of this process I focused on a thematic analysis approach to
examining the research data. Content analysis is described by the author as a
process o f analysis that deals with researcher derived categories (Marlow, 2011)

67
Guba and Lincoln (1981) provided criteria for assessing the reliability and validity of a
qualitative study. They substituted reliability and validity with the analogous concept of
"trustworthiness," which contains four aspects: credibility, transferability, dependability, and
confirmability (Morse et al, 2002).

Credibility. Guba and Lincoln (1981) assert that when conducting qualitative
research steps must be taken to ensure the "degree to which findings make sense" (Finlay,
2006, p. 7). Steps were taken during the research process to conduct member checks in order
to substantiate the credibility of the findings (Finlay, 2006). This process was conducted by
providing participants with a digital copy o f the interview transcripts. Participant feedback
has not been received to date. Another step taken to substantiate credibility was to provide
my academic advisor with a copy of all transcripts and periodic debriefings.

Transferability. To enhance the transferability of my research findings I chose a
convenience purposive sampling strategy through the selection o f participants that are
relevant to the research focus (Bryman, 2008). When conducting qualitative research a
comprehensive depiction of the setting must be provided, granting the reader sufficient
information to "judge the applicability o f the findings to other settings" (Finlay, 2006, p. 8).
In the collection of my research data I included rich, descriptive detail to assist future
researchers in assessing the applicability of the findings.

Dependability. Qualitative research must ensure the provision o f an "an audit trail"
(Finlay, 2006, p. 8) through documentation that clearly captures the methods and processes
used to make decisions about the research. To enhance dependability I maintained an audit
trail that includes interview transcripts, journal entries, and notes (Finlay, 2006).

Confirmability. A "self-critically reflexive analysis" (Finlay, 2006, p. 8) of my
research approach was incorporated to support the confirmability of the findings. Steps were

68
taken to ensure that research outcomes were the result of participant experiences and ideas
through the use of self-reflection and by having my academic advisor review the interview
transcripts. Journaling and consultation served to support the process of self-reflection, in
which I sought to consider and acknowledge my own predispositions (Finlay, 2006).
Additional guidance was found in Neuman’s (2003) coding and concept formation, as
well as Van Den Hoonaard’s (2012) open coding approach. These methods guided me in
organizing the data into “categories on the basis of themes” (Neuman, 2003, p. 441) while
ensuring that the process remained flexible in allowing for themes to emerge as informed by
the data by being mindful not to narrow the scope through the introduction of preconceived
ideas and while maintaining a spontaneous coding approach (Van Den Hoonaard, 2012).
The planning phase of this process began with thorough review o f all transcribed data,
as well as entries from my personal journal. This process allowed me to revisit the stories
and responses from participants, while giving consideration to personal insight and ideas,
while being mindful o f my role within the context of the research.
In identifying the categories I was mindful to apply an inductive method, described by
Marlow (2011) as reasoning that “uses observation to examine the particulars of a
phenomenon and then develops generalizations to explain or describe relationships among
the particulars” (p. 11). I began by coding trends within the data that were relevant to the
research. The coding process was guided by Tutty, Rothery, and Grinnell’s (as cited in
Marlow, 2011, p. 216) coding leveling system, which suggests two types o f coding and
categorization. The “first level of coding” (p. 217) concentrates on identifying trends, coding
them, and fitting them into categories. I conducted this process by reading the transcripts for
each participant, then re-reading them and highlighting trends that were evident throughout
the data gathered from all participants. Different colours were used to identify specific

69
trends. I then proceeded to review the data again for each participant transcript, as guided by
the coloured classifications, to verify the contextual significance o f the trends that were
identified. A single coloured classification was reviewed for each participant before moving
on to the next categorization. This process was followed by the assignation o f codes, which
were then revisited to determine relationships amongst the various codes and classifying
them into categories. The second level of coding, which is the one I chose to apply for my
data analysis, involved the interpretation of data and looked for “similarities and differences
between the categories as a first step in finding relationships” (p. 218). This process
involved the comparison of data from all participants and the integration of categories into
themes (Marlow, 2011). Once again I relied on Tutty, Rothery, and Grinnell’s (as cited in
Marlow, 2011, p. 216) approach to data analysis. This approach interpreted the data through
the development o f classification systems, which may include: cluster diagrams, matrices,
counts, metaphors, missing links, and contradictory evidence. I used the cluster diagram
system to assist me in this process. In the diagram, categories were identified by circular
shapes and themes were identified by rectangular shapes. As categories came together to
forms themes they were placed in their circular form inside the rectangular shaped theme
they informed.

Summary
Chapter three explored my research’s theoretical orientation and methodology. I
identified a qualitative approach as the selected research method. This choice was further
refined by constructivist influences. The research approach is enhanced by a descriptive
research strategy and through the application o f a Thematic Analysis approach. I gave
additional contemplation to the research population and sampling strategies, the formulation

70
of the research questions, ethical considerations, consent protocols, interview methods, as
well as the applicability and value of validity and reflexivity strategies. The process of
analyzing the research data adopted an inductive approach that allowed for the data to guide
the formulation o f the codes, categories, and themes. Marlow’s (2011) dimensions of
qualitative analysis provided additional guidance in organizing the data, identifying the
categories, interpreting the findings, validating the data, and conducting a thematic analysis
o f the research data. Furthermore, Guba and Lincoln's (1981) trustworthiness criteria
provided an important framework for supporting a valid and reliable research process, as
guided by the tenets o f credibility, transferability, dependability, and confirmability.
Standards o f conduct for this research sought to avoid deception, exploitation, and abusive
behaviours (Carey, 2012). Reflexivity was supported through the use of personal journals
that captured my responses, insight, and positional stance in the research.

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Chapter Four: Research Findings
...I think that i f you're weaving the spiritual element into your
practice then integration will be the natural way to be. (Participant)

In this chapter I will review the findings from my research and will include excerpts
from both interview transcripts and my reflective journal in order to support a holistic,
transparent, and well-rounded analysis of the process.

Thematic Findings

The process of identifying the themes entailed an initial review of all interview
transcripts, followed by a review of each individual participant’s response to each of the
research areas o f interest as captured through the interview questions. A colour coding
system was used to identify trends in the data. This system was then used to guide a re­
review of data for each participant transcript. The next step involved the interpretation of
data and the search for relationships and variations. This process then revealed categories,
which depict the underlying nature of the research themes. Once the themes were identified,
I proceeded to define and support them through excerpts from the research data.
The results o f this analysis revealed seven themes from the participant data. These
themes, hereby referred to as structural themes, were informed by 16 categories, which
include: collaboration, trust, respect, socioeconomic, organizational, budgetary resources,
human resources, internal and external supports, client’s role, clinician’s role, time, physical,
holistic, individualized versus one size fits all, and punitive versus therapeutic. Structural
themes are depicted as follows: relationships, historical factors, political drivers, supports,
roles, environment, and approaches. Categories emerged through participants’ responses to
the research questions. These categories were then analyzed for likenesses and disparities

72
that further revealed relationships amongst them, grouping them into themes. A conceptual
representation in the form o f a cluster diagram of both categories, captured in circular shapes,
and structural themes, captured in rectangular shapes, is depicted in Figure 1.

Figure 1
Map o f Thematic Analysis
Relationships

Supports
Collaboration

Respect

External
Internal

Trust

I

1

Historical Factors
-

/

X

Roles

_____

Organizational \
^

/
[

Socio\
economic
|

I
I

t

^

^ in ic ia n ^

I

1

--------- ►

1

I
Political Drivers

^—----- ^
f

\
/

1

Human
Resources

\
\

/
1

Budgetary
Resources

Environment

Q KJ

\
\
I

'N .

------- ^

i

I

Approaches
Holistic

Therapeutic
Versus
Punitive

Individualized
versus onesize fits all

Note:
The arrows represent the interconnectedness amongst all the structural themes. Structural
themes are captured in rectangular shapes and categories are captured in circular shapes.

/ T ~ " \
/ ^pace
\

73

Participants offered a wealth of insight concerning the impact o f mainstream mental
health approaches on the development of relationships through their hindrance on the
establishment o f trust and respect with service users, their families, and community partners.
These approaches were said to place the clinician in the “driver’s seat”, which in turn
promotes “power over” approaches that hinder the client’s willingness to participate in these
services. These approaches were also described as non-conducive to collaborative methods
o f practice. Furthermore, participants stated these approaches fail to account for historical
factors, including socioeconomic and organization specific. The impact of political drivers
on the systems that support mainstream approaches were also identified by participants as an
additional limitation of these methods. Mainstream approaches were described as promoting
a more punitive approach to service delivery as opposed to a therapeutically-minded
approach. Additional barriers include environmental factors such as restrictive time lines
and rigid spatial considerations.
In response to questions concerning supports and resources available to understand
and implement integrated strategies, participants identified key trends in these areas,
including perceptions o f localized leadership support and disinterest from higher levels of
leadership as influenced by political drivers; limitations on internal educational and skill
development resources; the substantially positive impact of external resources, including
community skill development and educational opportunities, cohort support and
collaboration, and the insight and knowledge gained from those being served.
Valuable insight was gained on the impact and benefits of implementing integrated
approaches through participant feedback as captured by key themes such as client
empowerment through more active engagement of the client in the development and
implementation o f treatment plans. In addition, the client’s family and community are

74
engaged through more holistic therapeutic approaches, which in turn result in improved
outcomes for the client. Individualized treatment plans replace one size fits all approaches
and time and spatial barriers are overcome through responsive approaches that allow for
more flexible methods o f engaging and supporting the client. By promoting collaborative
approaches, the establishment of trusting and respectful partnerships with clients and other
members of the professional community are supported.
My research was also concerned with the systemic challenges faced by clinicians
while trying to implement integrated strategies. Participant feedback shed light on this
matter, including the role of political drivers and how changes in priorities have a direct
impact on available resources, including professional and financial. In addition, participants
described how organization supports needed to implement innovative strategies will
fluctuate, creating gaps in service delivery, which in turn have a direct impact on the
relationships that clinicians have forged with clients, families, communities, and other
professionals. These systemic challenges are also said to perpetuate the historical trauma
often present within Aboriginal populations, hence reinforcing existing fear and distrust of
the organization. I will now proceed with a review of the structural themes with categories
becoming a part o f the structural focus.

Themes
1.

Relationships. The role and relevance o f relationships within the context of

the therapeutic environment was a common theme for all participants. This is a structural
theme because it depicts the structure of the therapeutic relationship. The relationship
between the clinician and the client is described as a key component of a successful
therapeutic intervention. Relationships were described in terms of how mainstream

75
approaches hinder the trust, respect, and collaboration needed to foster relationship building
with clients, their families, and communities, as exemplified by the following participant
statements:
.. .1 do find that even for some of the Aboriginal clients who may initially reach out to
my agency, even just the nature in our initial intake process. It's a lot of paperwork
and a lot of cheeky boxes and it's not focused on the relational aspect as much or the
conversational aspect as much, which we know to be so important when we're
working with different First Nations clients.
... we have some screening tools that help determine eligibility for service and some
of those screening tools are actually quite intrusive. For all families but in particular
to the First Nations community, because they're asking questions about
demographics, so aah income, education level, the wording at times of the questions
aah I feel we're not culturally sensitive enough and depending on who the clinician
and practitioner that's delivering that training tool it may either you know hinder the
relationship.
Another key aspect of relationships is that of collaboration. Participants describe their
partnerships with other professionals and community partners as key in the delivery of
successful supports and interventions. Working in isolation is depicted as “arrogant” and
“self-defeating”. Participants further elaborate on the value of collaborative approaches:
I don't just consult with other counselors I like to consult with lawyers, with our team,
with people who are actively living with addiction, with whoever, just people that are
going to give me a different way to look at the situation and a different way to kind of
explore what's going on even for myself.
.. .There is always a collaborative area to allow the client to be actively involved in
their own healing process...

Participants also reflected on the impact relationships have on the development o f their
practice:
What I try to share with my clients early on in our relationship is that I'm still
learning and there are many different ways to heal and to feel good and it's going to
be different person to person and so part of our journey together is that we're both
gonna stumble and we're both gonna succeed and we're both gonna learn from each
other and so it's a partnership, it's not an expert trying to help this person in trouble, I
just think that's just so disrespectful that mindset to a client. I find that my clients
help me just as much as I help them and I think it's a real equalizer in the relationship

76
for clients to...and empowering for the client to buy into that, that they're helping me
learn about my practice and myself... that I can really judge our relationship when I
get to a point with the client where they can say oh that did not work you know do
that, the way you tried to do that today, oooh that fell flat.
All participants offered insight as to the value of relationship building and collaboration in
supporting an effective therapeutic process. The impact of mainstream approaches on this
key aspect o f the therapeutic process was described by three of the four participants as
detrimental, due to its fundamental limitations and failure to allow for the type o f flexibility
needed to nurture relationships in a respectful and responsive manner.

Reflection Journal. I t ’s amazing how we continue to disrespect people, treating
them like children and continuing to make the same mistakes from our past. I really hope
someday the ideas and passion o f people like these become infectious and spread in such a
way that will shake this flaw ed system to its core. When I think o f all I learned from my
clients I can't help but wonder how I would have done the work without them. I couldn ’t and
wouldn ’t have gotten very fa r at all.

2.

Historical factors. This theme reflected the participants perspectives on the

impact o f historical occurrences on modem practice. This theme is structural because it
focuses on the historical structures that have influenced the clinician's role and experience
within the therapeutic context. The impact of historical socioeconomic pressures on the
health and well-being o f Aboriginal individuals, families, and communities is eloquently
captured in this participant statement:
... You know you might be dealing with a family intergenerational residential school.
Maybe the younger kids aren't exposed to the school itself, but they are exposed to
the results o f it and they live it day in and day o u t . You know and you walk into a
classroom maybe in that community and seventy to eighty percent o f kids have PTSD
you know and that's their daily life as a result of living with parents, grandparents
who attended residential school and all the things that went with that...

77
Another important historical factor that presented as a concern for three out of the four
participants is that o f organizational considerations as it related to historical occurrences of
negative encounters with specific branches o f government. Participants described this issue
as a barrier they commonly encounter in their practice:
... Some families may have not had the best experience aah with the ministry or they,
they could've had a child in foster care aah and so it brings back you know or
potentially could bring back you know some post-traumatic stress or aah anxiety
around entering the building, around engaging or knowing that you know mental
health is attached you know to the other programs within the ministry...

Reflection Journal. I t’s tough working fo r an organization that's linked to so much
pain. The history is so fresh in p e o p le ’s minds and then o f course so much o f it remains
ongoing. It took decades, centuries to cause this much damage, i t ’s gonna take maybe that
long fo r the wounds to heal completely or is that possible? I think so. I really hope so.

3.

Political drivers. This theme sets the context for understanding the impact of

political priorities on resources needed to deliver consistent, reliable, and culturally safe
supports. Participants identified two primary resources commonly impacted by the political
climate, which include personnel or human and budgetary means. Political drivers were
deemed a structural theme as they depict the external structures that have a direct impact on
the therapeutic environment. These challenges are described in detail by three out o f the four
participants:

I've been in a situation a year and a half ago I stopped going to a region because they
changed the health delivery area and a year and half later there are still no services
being provided by this other, other regional delivery.
On a provincial level where you have crisis on a small community and is public
knowledge then you know maybe four, five people go into a community try to deal
with a bunch of crisis there's nothing consistent, nothing ongoing, and then you fly
back out and you've got ministers and deputy ministers waiting with baited breath to
see what the team did on the ground sort o f speak right.

78
One participant sheds a glimmer o f hope in this bleak outlook on the impact of political
priorities on the efficacy o f services and interventions:
.. .These past couple o f years, the liberal government they are so open to and also
they raise the awareness in respecting the Aboriginal culture....Kind of like the
government is making up for what they have done in the past.

Reflection Journal. I t ’s interesting to hear that no matter where you go the same
issues seem to be present. How do you establish rapport with people when you constantly
get the rug pulled from under you? I remember this when I was working with families and
much work was involved in mending relationships after political changes took place. I t’s so
very frustrating to not be involved in the types o f decisions that impact the quality o f the
work you do and the families you serve.

4.

Supports. This theme is structural because it focuses on the internal and

external structures that impact the clinician's experience and perspective on the delivery of
integrated approaches. In response to the question concerning the clinician’s perception of
support in delivering integrated supports all participants agreed that a combination of both
internal and external supports come together to shape the delivery o f integrated approaches.
As it relates to internal supports, participants described local leadership as the most
influential source o f support in developing an integrated practice and delivering integrated
supports:

So there are traditions and practices that really resonate with me and so aah what I
needed to do as like a frontline worker.. .is to get to learn the practices of the
community and so it was very important for me to integrate that into my practice.. .So
it was very much supported and embraced.. .by my team leader when I first started
with the ministry.
...Within the First Nations communities...there are opportunities within the
community whereby you can...as the practitioner...can go attend some of the events.
I've been in the role of a team leader so I looked for those things and I encouraged my
staff to go and.. .my supervisor supported that.

79
External sources o f support for developing an integrated approach to service delivery are
described by participants in terms of both formal and collaborative opportunities within the
community:
.. .1 am actually involved in an Aboriginal support group, so they taught me, so this is
what we use and this is what we don't use. They taught me about the history and so
this is how I learned...

Reflection Journal. I know this already but it is interesting to hear from front line
staff that internal resources are perceived as limited. We work fo r such a large organization
that delivers services to a multitude o f cultures, why don't we have more internal resources
available to us as practitioners and administrators? I know the online cultural training I did
was really awesome, but again not put by us. Is it maybe about mapping out the resources
and making that information more readily available? Uuhm, fo o d fo r thought.

5.

Roles. Participants described the roles of both the clinician and the client as

key in the delivery o f effective integrated approaches. This theme is structural due to its
focus on the structural nature o f the therapeutic relationship. The role o f the clinician is
described as key in guiding both the timing and approach to the delivery o f integrated
supports:
.. .It's not so much of the approach itself, because the approach is dead, but the
clinician is alive, it is the clinician's responsibility to implement that...
The clinician’s role is also described in terms of personal initiative and accountability, as it
relates to knowledge expansion and skill development and its impact on the advancement of
professional capacities:
So you as the practitioner need to integrate that into your own being in order to have
an integrative practice.
The role o f the client is described in terms of how it serves to support the development of
professional capacities:

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So and then there was another time and we were passing the talking stick around in
the support group thinking that this is the cultural practice the talking stick, the
Elders. They actually are quite all of them, quite uncomfortable having the stick
passed to them. Even though we have given them the option to talk or not to talk.
The cultural practice when we implemented that I feel that we have to also consider
from a client's perspective.
The role of the client is also described in terms on how it serves to further the priorities of
inclusive, culturally safe integrated approaches:
The integrated approach really depends on client feedback as well and I think that it's
really important to keep checking with the client about, you know are you happy with
what we're doing, how could I be doing this better, you know this is what I tried to do
today, did I succeed? Oh I could've done it that way, oh that's good. You know and
so we just kind o f just communicate back and forth and always be trying to find the
right path together.

Reflection Journal. I can so relate to what is being said. I knew so little about
Aboriginal culture when Ifirst moved here. I wouldn ’t have gotten very fa r in my work if the
people I worked with and the people I served didn 't take pity on me and walk me through the
101 o f cultural sensitivity. 1 loved the history lessons and they really helped me understand
the journey o f the peoples o f this land.

6.

Environment. This is a structural theme as it depicts the various physical

structures that have a direct impact on the therapeutic environment. The challenges of
implementing integrated approaches were often described in terms of time and space. These
barriers were said to reflect the tenets of mainstream approaches that work within rigid
structures, which when applied to integrated forms for intervention do not fail to
accommodate the environmental factors needed to promote these innovative forms of
practice:
.. .We're very much a nine to five kind of agency, the fifty minute sessions and even
that it's not a good cultural fit for a lot of people... one o f our partner agencies that
we try to work with, they do different hours and more flexible hours later in the day.
They operate on a looser time frame. Things like that that are just better
considerations that they're using in their practice which I think would be great if we
could start to incorporate a little bit more of that in our agency as well.

81

Hopeful examples were provided of instances when flexibility was incorporated into clinical
interventions, thus allowing for more responsive and effective therapeutic supports:
I find certain things like allowing greater amounts of time or more flexible time,
being flexible on where to meet, being mindful of cultural significant events and
dates or different occurrences within the community. In my community we've been
so saddened by recent death and so having mindfulness that there are certain cultural
practices that take place after a death that need to be observed that this is not the time
for business, this is the time for mourning, and to have that knowledge that you can
be culturally respectful, appropriate.
Reflection Journal. Illness is not a nine to five thing, yet we keep treating it that
way. I t’s fu m y how we keep trying to make people fit into our little boxes even though we
understand the nature o f the disease. How can we expect to build trust when we don ’t offer
respect and consideration? It is so lovely to hear about the amazing work th at’s happening
out there. I wish I could be a part o f it.

7. Approaches. This is a structural theme that depicts the structural processes that
inform and guide the therapeutic experience. Comparisons between the nature of
mainstream approaches and that of integrated interventions often reflected on the
punitive nature of the former and the therapeutic intent o f the latter:
...Alcohol, drugs, you know sexual intrusiveness, things like that...This is expected
behaviour when over a number of decades this is become the norm. You know a lot
of it perpetuated by what happened to the older people in residential schools and then
what they’ve done to the next generation and then the next generation and then you
know communities being scared to death to address that stuff because of the way
things are set up they have to do it on a punitive level.
The importance o f adopting holistic methods of intervention is described in terms of their
impact on the health and wellness of the people we serve:
... When we try to treat the individual out of context of their family and their people
and I think that's not as productive as recognizing this individual as part o f an
inclusive society.

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The efficacy of therapeutic approaches is also described in terms of individualized methods
versus the one-size-fits-all slant and the impact these techniques have on cultural safety and
client outcomes:
... You can't assume that you know one region practices smudging and the other is or
one uses sweat lodge and the other one doesn't and our practices back east was to
offer tobacco to our Elders if we are going to ask them for something and then
blankets and when I came here when I asked well do you do that, but that wasn't all
across BC so everybody is different.
I think it's very important to be mindful of who the client wants involved in their
integrated treatment plan, because they may have had experiences with teacher or
with elders or with social workers that have not been positive and so I think it's we
can't make assumptions that who should be sitting at that table, again one size does
not fit all, we really need the client or their family to dictate who we invite be part of
that process.

Reflection Journal. I know I resent others when they try to treat me like they know
me and shouldn 't come as a surprise that th at’s not a good way to practice. I ’ve learned so
much through this process, especially about the traditional holistic view o f the individual.
I t’s so brilliant and logical when you think about it. I love the idea o f working
collaboratively, in partnership with your client. I really miss working with families and ca n ’t
wait to get back to doing what I love.

Additional Considerations

Participants explored additional areas of interest that were not deemed as having a
direct link to the primary research themes, but were believed to be a complementary addition
to the research findings. The supplemental topics included considerations for conceptual
meanings and rural practice. Participants considered how conceptual meanings derived from
both professional experiences and client interactions can impact the therapeutic experience.
This is vividly captured by the following participant statement:

83
We're currently defining mental health by mental illness, by all these negative
barriers, and negative factors, and I know in my current job to qualify for our services
you need an a variety o f symptoms that are hurting your functioning. So what a lot of
the people at the Aboriginal psychology session were saying is that mental health for
Aboriginal clients really needs to be defined as health, not an abundance of negative
factors, but almost an absence of the positives. We need to focus more on building
healthy habits versus focusing on negative diagnostic criteria...
Concerning rural practice, a participant describes both the challenges and strengths of
delivering services in rural and remote communities:
...I practice right now in a small community and there's so many difficulties with that
certainly don't have as many resources as a big city, but there's also just so many
strengths in being in a small community, in that we can work so nicely together and
kind o f have a team approach to really treating some of the big systemic things that
are happening in our own back yard and we all have different areas of specialization.

Summary

As I consider the intent o f this research in exploring the challenges and benefits to
integrating traditional Aboriginal healing practices and mainstream mental health approaches
and the themes that emerged from participant feedback, I find myself in awe of the richness
and insightful nature o f these findings, while at the same time feeling humbled by the
amazing work that is happening in our communities and the realization that I have so much
to learn about culturally relevant and meaningful practice.

84

Chapter Five: Discussion, Implications, and Recommendations
An integrated approach is not ju st throwing a bunch o f modalities and
resources into a blender and ju st taking out what half hazardly falls out,
it needs to be very mindful. (Participant)

Discussion

This chapter will capture the process of exploring how the research findings
substantiate or fail to substantiate the research purpose and objectives. In addition, the
ensuing implications, including the limitations of the research findings will be explored, and
recommendations will be made within the context of organizational, practice, and academic
realms.
This research was guided by both its objectives and the principal query. The research
objectives sought to capture the experiences and perspectives of clinicians as they relate to
the integration o f integrated mental health approaches. They also set to explore the impact of
policies and programming on these integrated methods. Research objectives also set out to
establish an improved understanding of how integrated approaches comprise a unique form
o f practice.
In my research I sought to describe the challenges and benefits to integrating
traditional Aboriginal healing practices and mainstream mental health approaches from the
perspectives o f child youth mental health clinicians. Through a qualitative, constructivist
lens, I carried out a descriptive approach to my research. This process was facilitated
through the research interview questions. The questions guided participants in exploring the
limitations o f mainstream mental health approaches in their capacity to deliver culturally
relevant supports to Aboriginal populations. The clinician's experience in learning about and

85
implementing integrated approaches was also explored. Timeliness and effectiveness were
also explored. The perceived deficits and strengths of integrated approaches were also
explored. Clinicians are also prompted to describe the supports and systemic challenges they
faced in their efforts to implement integrated strategies.
All research components were brought together through the support and generous
contributions o f four dedicated professionals, delivering supports to vulnerable individuals,
families, and communities in the Northern region of B.C. These professionals walked me
through the realities o f delivering culturally safe integrated mental health supports, while
working within a bureaucratic system.
In looking at descriptions o f professional experiences specific to the implementation
of integrated approaches to mental health service delivery, participants offered a great deal of
detail around their experiences and the impact on both their practice and outcomes for their
clients, this was described as "meeting the individual where they're at". The importance o f
developing relationships with clients is a key aspect of successfully integrating modalities.
In exploring integrated approaches and the degree to which they support the
constructs o f established culturally relevant priorities in local and national policies, we did
not examine national policy, but participants were able to describe how integrated
approaches support local cultural priorities and how overcoming mainstream barriers
becomes a focal point o f that process. More people could be served and services could be
more effective if we focused more on building the strengths of the client and avoiding
approaches that focus on negative diagnostic criteria. By focusing on developing a respectful
and collaborative environment outcomes for Aboriginal clients can be improved.
In looking at how the research has furthered the objective to increase awareness and
understanding of how traditional Aboriginal healing practices and mainstream approaches

86

have come together to create a unique form o f service delivery, one only needs to turn back
to participant feedback on all areas o f interest to appreciate the impact their contributions
have made in gaining improved awareness and understanding of the realities of
implementing integrated approaches.
The research findings shed vast light into the systemic challenges encountered by
professionals in their efforts to develop and deliver integrated mental health approaches,
including the impact of political drivers on human and budgetary resources, and the various
levels o f support, both internal and external to the organization. One aspect of this topic that
is o f interest is despite the numerous barriers encountered in their practice, most participants
remain optimistic about organizational improvements and overall commitment to cultivating
service efficacy and cultural safety.
In exploring the impact o f integrated approaches on client outcomes, participants
describe processes that serve to empower, heal, and strengthen individuals, families, and
communities. By "using what the client identifies as their own strengths and interests" the
clinician paves the way for a mutually respectful environment. Even when a certain
approach fails, the therapeutic relationship is strengthened.
Integrated approaches have consistently been described by participants as “relevant”,
“flexible” and “well-received”. Their experiences provided a roadmap to understanding the
limitations of mainstream approaches, the benefits of implementing integrated approaches,
the very real challenges in delivering these methods and the significant supports that make it
possible to incorporate these innovative practices.

87

Links to Literature

Strong linkage was found between the research findings and the literature.
Participants described the importance of acknowledging the interconnectedness between the
individual’s physical, mental, spiritual, and emotional make up. These findings support the
framework for culturally safe practice that guides Canadian policies concerned with the
delivery o f mental health services to Aboriginal populations (Canadian Institute for Health
Information, 2013). Research findings can also be linked to literary resources concerning
research priorities. Participant feedback exemplifies research considerations for both the
historical and ongoing challenges faced by Indigenous populations (Smith, 1999).
Additional linkages include participant reflection and insight on the impact of conflicting
priorities between the dominant culture and Aboriginal structures that result in the loss of
cultural identity and vulnerability to insensitive dominant culture paradigms (Cannon &
Sunseri, 2011).

Implications for Social Work Practice
This section is concerned with the inferences of this research, as it relates to three
primary areas o f interest, organizational, practical, and academic, within the context of social
work practice. I will explore what the findings mean within the context o f each sphere and
consider any occurrences o f overlap.
Additional implications are related to my role as the primary researcher. My decision
to apply an interpretive process required me to remain cognizant o f the potential impact of
my association with the same organization from which the research sample was selected.
The sharing of a common language or internal organizational knowledge was considered in
its potential impact on the integrity of data being collected. A commitment to ensuring the

88

veracity o f my research findings led to the decision to utilize reflexive journaling as a tool to
support a clear and accountable research process. Through this method of self-reflection, I
was able to give ongoing consideration to my role and its potential impact on the research
process.

Organizational

The findings suggest that social work organizational structures serve to both promote
and hinder the development and implementation o f integrated strategies. The previous
chapter explored participants’ perceptions concerning systemic challenges and supports.
Through this research I discovered that professionals are often faced with politically driven
barriers, which often translate into deficiencies in human and budgetary resources. These
deficiencies result in limitations to service access, gaps in services, and the abandonment of
integrated approaches in favour of mainstream methods that offer perceived savings through
reductions in service hours, outreach supports, and innovative endeavours. Systemic issues
were also considered through perspectives that take into account the historical issues that
may impact access to services and the overall influence o f such services. Participants
explored client perspectives on the historic relationship between Aboriginal communities and
certain branches of government, including the Ministry of Children and Family
Development. These historic ties often present as barriers in engaging clients, as this
government entity is often associated with intrusive and harmful interventions. Participants
went on to describe the various tactics, derived from integrated approaches that are used to
support clients in overcoming their fears, developing a sense of trust, and ultimately
engaging in services.

89

Practical

The research findings present various implications related to practical applications in
the field o f social work. In the delivery o f services, participants described how integrated
approaches served to empower individuals, families, and communities. The methods
promote collaborative approaches that foster an environment of respect and trust.
Participants also described the shift from punitive methods towards more therapeutic
approaches that seek to acknowledge the inherent value of all individuals. Aboriginal
knowledge is incorporated into these holistic supports that understand the inextricable link
between the individual and their environment. Individually tailored supports acknowledge
the uniqueness of sub-cultures within the Aboriginal culture, thus promoting responsive,
culturally safe interventions. The role of the client within the context of the therapeutic
environment is enhanced through these innovative practices, as supported by collaborative
approaches that acknowledge the client’s contributions as key in achieving success. In
addition, the role o f the clinician is downplayed from that of the primary knowledge holder,
as seen in mainstream approaches, to more of guide that seeks to support the client through
respectful partnership in discovering and exploring the knowledge and strengths he or she
already possesses.

Academic
Research findings suggest that academic considerations must be given to the
emphasis placed on the development of culturally responsive practices. The role of academia
in supporting the development of innovative, culturally sensitive practitioners is one of
undeniable importance. Academic training serves to shape professional standards of social
work practice, which in turn impact outcomes for individuals, families, and their

90
communities. The diverse nature of Canadian culture should demand a revision o f academic
standards to capture the richness o f knowledge this diversity puts at our disposal. Cultural
relevance should become a standard addition to academic curricula, inviting developing
professionals to explore the vast knowledge that is available not only through scholarly
channels, but through organic, traditional methods that reflect human adaptability and
wisdom.

Limitations of the Research

Despite the best intentions of this research, limitations are present. These limitations
must be explored in order to allow for the opportunity to reflect on lessons learned and the
exploration of future possibilities. The research scope only captured the experiences and
perspectives o f professionals working for one governmental entity. Failure to capture the
voices of clinical staff from other branches of government, Aboriginal agencies, social
service agencies, and private practice presents as the most significant limitation in this
research. Furthermore, a broader research sample, inclusive o f clinical experiences across
the country from both public service and private sector populations, would serve to give fair
consideration to the implications of such experiences as they related to national policies and
directives.

Recommendations
The participants in this research offered insightful and valuable recommendations for
change. Participant responses to the interview questions suggested that internally informed
systems are limited by like-minded organizational thinking, this is evidenced by the
following participant statement “decisions and changes are made that don’t capture what
families and communities experience”. Professional implications from an organizational

91
stance include the need to strengthen the capacity of external review bodies in their ability to
analyze and determine the effectiveness of policies and programming aimed at addressing the
needs o f multicultural populations. The development of capacity for external review
processes must be informed by evidence-based or culturally accepted methods that reflect the
use o f up-to-date, reputable resources. Another important consideration is the inclusion of a
diverse cultural representation, as part of these external processes. The engagement of
Aboriginal organizations and Aboriginal community representatives can support the delivery
of culturally sensitive, inclusive processes that will serve to improve the effectiveness of
services being delivered.
Practical considerations suggest a shift towards more flexible and collaborativelybased social work service delivery structures. Participants believed that at the local level
supports are available to "think outside the box", but admit that "bureaucratic limitations"
can limit those opportunities. Integrative collaborative practice is described as the key to
delivering more holistic supports. Practitioners must be supported in their efforts to deliver
culturally relevant services through readily accessible, well-informed, and culturally
sensitive supports. Culturally sensitive supports may include training opportunities for front­
line practitioners and supervisory staff, as well as facilitated access to up-to-date relevant
professional development materials. It is essential for practitioners to have access to
supportive work environments that accommodate flexible schedules and service access
points, as well as collaborative and inclusive approaches to service delivery.
Participants also noted that schools of social work need to further develop curriculum
content and practicum placements specific to the development of skills in implementing
integrated approaches, as captured in the following participant statements:
.. .1 wish they would’ve had more at school about this integration stuff.

92
Learning about this kind o f thing and being able to put it to practice would really
help...
It was also pointed out that these changes should be informed by “people who know the
culture”, which may include, but should not be limited to Aboriginal community
stakeholders, Aboriginally-based scholarly materials, and traditional knowledge.
Consideration should also be given to the social work professional community's role in
“talking about and pushing change” as it relates to the implementation of policies and
resources that support the development of integrated mental health approaches.

Summary

In its focus to capture the voices of mental health clinicians concerning their
experiences with the implementation of integrated approaches, my research revealed various
themes. These findings suggested possible implications for the field of social work in areas
such as organization, practice, and academia. The research findings also supported
recommended changes in organizational specific areas, such as training and practice. In
considering the limitations o f my research, special attention was given to the scope of the
research sample and the constraints it poses concerning the applicability of the research
findings from a global perspective.

Conclusion
The process o f conceptualizing and implementing this research from the perspective
of a novice researcher can only be described as enlightening and inspiring. As I sought to
determine my research focus, I found both my personal and professional background
directing me towards an improved understanding o f culturally relevant practices. This
direction was further refined by my passion for mental health practice and a deeply set

93
interest in gaining a better understanding of innovative practices in that field. These two
pieces came together to shape the direction o f my research. As I set out to explore the
experiences o f mental health professionals in the implementation of integrated practices, I
was unsure what the process would reveal.
The intent to explore rather than generate new knowledge led me to the decision to
select a qualitative research approach, as guided by a constructivist lens, and further refined
through an exploratory method. The data gathering process was supported through an
interview approach, as guided by predetermined questions. The questions guided these
discussions, supporting the research scope and objectives. This collaboration resulted in a
process that led me to understand the topic of interest from the various perspectives of
professionals faced with the realities of implementing the work.
The process o f interpreting the research findings and identifying common themes
throughout the data was facilitated by the process of reviewing the data while transcribing
the recordings. The use of a reflective journal served to enhance this experience and was
instrumental in maintaining an ethical stance and being mindful of my personal views while
giving meaning to the information that was gathered.
I believe that in capturing the perspectives of professionals delivering the services
that are conceptualized at higher levels of the hierarchical structure credence is granted to
value efforts that promote more collaborative approaches and the design of service delivery
structures that reflect the realities o f day to day practice. Despite the perceived benefits of
the research findings, I believe that more research is necessary to capture the voices of
mental health professionals in their experiences as shaped by the various and unique settings
in which services are being delivered, not just across the province, but across the nation.

94

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Appendix A: Information Letter
Date:

Title of Study: “Clinical Perspectives on the Integration of Mainstream Mental Health
Approaches and Traditional Healing Practices”

Esteemed Professional:
This letter is intended to provide you with information on a thesis research project concerned
with the professional perspectives of CYMH clinicians on the integration of mainstream
mental health approaches and traditional healing practices, which is being conducted by
University o f Northern British Columbia Masters of Social Work student and researcher
Marcela Rojas. Ms. Rojas also presently holds the title of Utilization Services Coordinator
with the Ministry o f Children and Family Development (MCFD).
The purpose of this project is supported through the identified research objectives, as
follows:
To describe professional experiences specific to the implementation of integrated approaches
to mental health service delivery
To explore integrated approaches and the degree to which they support the constructs of
established culturally relevant priorities in local and national policies
To increase awareness and understanding of how traditional Aboriginal healing practices and
mainstream approaches have come together to create a unique form of service delivery
To explore how existing systems support or fail to support the development and delivery of
integrated mental health services and supports
To explore professional perspectives on the impact o f integrated approaches on client
outcomes
The research seeks to promote the examination of systemic barriers; explore training
opportunities and how these coincide with the needs of practicing clinicians; the impact of
clinical support and supervision; and consider the value of existing frameworks for practice
that support the delivery o f integrated approaches.
Respondents will be chosen from a Microsoft Outlook address book listings of Child and
Youth Mental Health workers in the North Central, Northeast, and Northwest Service
Delivery Areas.
The previously identified researcher, Marcela Rojas is currently employed by MCFD, but
will be conducting her research solely in her role as a Master’s student and not as that of an
MCFD employee.
What will I be asked to do and what are my rights?
You are being asked to participate in a one to two hour interview. There is no right or wrong
way to answer and what you say is important to us. The researcher will conduct the

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interview. To assist the researcher, you will be asked for permission to audiotape the
session. Your permission will be required to proceed with the interview. These tapes are to
help ensure detailed information of what is said is accurately captured. Only the researcher
will hear the tapes, which will be transcribed by the researcher and used to inform the
objectives of the project. You will also be provided with an opportunity to review the
transcribed interview once the transcription is completed.
Personal journals will be used to support self-observation and as a tool for tracking research
progress and identifying existing or potential barriers.
Your participation is voluntary and you have the right to the confidentiality and anonymity of
any information you provide. As a participant, you also have the right to not answer any
question you choose and withdraw your information without consequences. Consents must
be electronic signed prior to participation. All electronic communications will be made
through UNBC’s e-mail server.
All personal identifying information about you will be kept confidential through the
production of anonymized transcriptions and through the assignment o f pseudonyms as
identifiers for each participant. Furthermore, no identifying information will be contained in
the final research document.
Interview data will only be accessible to the researcher and her supervisor for the purposes of
ensuring the proper data analysis. All research participants will be provided with a copy of
the final research report.
The data collected will be kept in a locked filing cabinet located in my office, a space which
is also locked and located at the MCFD regional office in Prince George, for the five years
following the publication of results and will remain the property of the researcher. At the end
of the study and publication time periods (maximum 5 years), all tapes will be erased,
electronic data deleted, journals will be destroyed, and any paper/hardcopies shredded.
What are the risks and benefits o f participating in this project?
The methods used will pose no or minimal risk to you as the interview questions will not be
sensitive, personal or psychologically invasive. There are no guaranteed benefits for your
participation in the evaluation process other than supporting the objectives of this project.
Please keep this information letter for your own records. If you have any questions about this
project, please contact my research supervisor, Joanna Pierce at 250-960-6521
(Joanna.Pierce@unbc.ca). For information on your rights as a research participant or if you
have any concerns or complaints about this project please contact the Research Ethics Board
(REB) at UNBC at 250-960-6735 (reb@unbc.cal. We sincerely thank you for your interest
in this study.

For additional information you may contact the project researcher:
Marcela Rojas

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Project Researcher
Phone: 250-981-7727 (cell)
E-mail: rojasm@unbc.ca

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Appendix B: Consent Form

Project: Clinical Perspectives on the Integration of Mainstream Mental Health Approaches
and Traditional Healing Practices

I ,_______________________ , undersigned, agree to participate in this interview as
described in the information letter with the main objective to assist the researcher in
gathering information to support the project objectives.
I have received and carefully read the information letter and understand that I am being
asked to participate in an interview for a duration of one to two hours. I understand that I am
also being asked to give my consent to audiotape the interview session for reasons of note
taking, and I have read how this and any other notes taken during the interview will be
handled in a confidential and anonymous manner.
I understand my rights as outlined in the information letter and that I can refuse to answer
any question without providing any reason for my decision. I understand that I can withdraw
from participating at any time during the interview. I have asked all the questions I had
regarding this interview and I am satisfied with the answers given to me.

□ I agree/disagree to participate in the interview session.
□ I agree/disagree to the audio taping of the interview session.

Name of Participant:

Signature:

Date (D/M/Year):

Witness:

Signature:

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Date (D/M/Year):

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Appendix C: Interview Questionnaire

1)

What limitations do mainstream mental health approaches present in delivering
culturally relevant supports to Aboriginal clients?

2)

Please provide examples o f instances when mainstream mental health approaches did
not work for Aboriginal clients

3)

How did you learn about integrated strategies?

4)

Please describe your experience in implementing integrated mental health supports

5)

Describe how you learned to implement integrated mental health supports?

6)

How did you know it was appropriate to use these strategies?

7)

How have integrated mental health supports worked for your clients?

8)

What do you believe are the deficits and strengths of integrated mental health
strategies?

9)

Were you supported in implementing these strategies? If so, how?

10) Have you encountered systemic challenges while trying to implement integrated
strategies?