Annotated Bibliography

Systematic Reviews of the Research Literature

Bennett, K.; Rhodes, A.; Duda, S.; Cheung, A.; Manassis, K.; Links, P.; Mushquash, C.; Braunberger, P.; Newton, A.; Kutcher, S.; Bridge, J.; Santos, R.; Manion, I.; McLennan, J.; Bagnell, A.; Lipman, E.; Rice, M.; and Szatmari, P. (2015). A youth suicide prevention plan for Canada: A systematic review of reviews. Canadian Journal of Psychiatry, 60(6), 245-257.

This is a systematic review of the literature about youth suicide prevention looking at randomized controlled trials (RCT) and controlled cohort studies. It does not look specifically at Aboriginal populations. The authors reviewed school based and non-school based interventions for youth up to 24 years of age.

They did not find evidence that school-based interventions led to a reduction in deaths by suicide, but they may reduce suicide attempts or ideation. “The recent RCT reporting a trend for increased suicidal ideation among Aboriginal people who receive ASIST (Applied Suicide Intervention Skills) gatekeeper training (that is, the gatekeepers) illustrates the need to evaluate both the benefits and the harms of interventions before widespread use” (p. 255).

Overall the findings of this review suggest that not enough evidence exists to make informed choices about youth suicide prevention interventions. More Indigenous research in particular is needed. The authors state “Currently, we suggest that First Nations, Inuit, and Métis colleagues, non-Indigenous clinical and research collaborators, and community-based service providers

review our [Expedited Knowledge Synthesis] general findings, and then consider their own unique cultural and contextual factors when formulating conclusions regarding relevance to the needs of the youth in their communities. We also acknowledge and support the need for community led and -based suicide prevention initiatives, including evaluation resources, such that unique contextual and cultural needs of Aboriginal communities are respected and incorporated into shorter- and longer-term planning” (p. 254).

Clifford, A.; Doran, C.; & Tsey, K. (2013). A systematic review of suicide prevention interventions targeting Indigenous peoples in Australia, United States, Canada, and New Zealand, BioMed Central Public Health, 13, 463-474.

Through a systematic review of the literature, the authors identified nine published evaluations of interventions targeting Indigenous peoples in Australia, United States Canada and New Zealand. Interventions included education, gatekeeper training, and community prevention approaches.

While there is insufficient evidence about which approaches are most effective in terms of preventing suicide, the authors make some recommendations based on their review of the literature. First, a recommendation is made for effective partnerships among government and research agencies, health-care providers and Indigenous health-care services. Second, there is a need for more “Indigenous-specific evidence,” and thus a recommendation is made to undertake more evaluations of culturally specific suicide prevention programs. Third, the authors recommend a coordinated approach to interventions that address a range of common risk factors, rather than addressing suicide in isolation – and that these should be developed in collaboration with Indigenous communities.

Fast, E. & Collin-Vezina, D. (2010). Historical trauma, race-based trauma, and resilience of Indigenous peoples: A literature review. First Peoples Child and Family Review, 5(1), 126-136.

This literature review attempts to bridge two bodies of research: those that focus on the damaging impacts of colonialism (which often address Indigenous populations in general terms) and those that focus on the resilience of particular peoples, communities, and Nations.

It begins by focusing on disparities between Indigenous and non-Indigenous people in general, pointing to – and examining a number of – colonial policies and practices as a way of understanding these disparities. It then examines a number of discourses around trauma, beginning with those that tend to psychologize trauma and then moving to more political and complex conceptualizations, including historical trauma.

This sets the stage for a discussion of resilient responses to trauma and discrimination which are themselves political rather than psychological, and include such things as self-governance and cultural and spiritual renewal. The authors urge that more be done to recognize not only residential school experiences – but also systemic losses of land, language and culture – for their impacts on trauma and resilience.

Current research demonstrates that culture is a protective factor for Indigenous people and communities, and supports “theoretical frameworks of intergenerational, historical, and race-based trauma” (p. 134). The authors do identify some limitations to the existing body of literature. They suggest more research be conducted among urban and remote/isolated communities, and people living off-reserve

Harder, H.; Rash, J.; Holyk, T.; Jovel, E.; & Harder, K. (2012). Indigenous youth suicide: A systemic review of the literature. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 10(1), 125-142.

This systematic review begins by contextualizing the issue of Indigenous Youth Suicide (IYS) globally and historically. This review aims to evaluate the rigor of existing literature and to assess the relative importance of risk and protective factors in existing studies, with a particular emphasis on culture. Only 23 articles met their criteria for inclusion in this review. Of the studies reviewed, four methodological strengths were identified: “1) community involvement; 2) pilot testing; 3) ensuring accuracy of data; and 4) controlling for, or limiting, the presence of extraneous influences” (p. 132).

In terms of risk and protective factors, the data weren’t sufficient for statistical analysis, however, the two strongest risk factors that emerged were depression and having a friend attempt or die by suicide. Support (social or familial) was the strongest protective factor identified, while high self-esteem was identified as a personality variable. Only six of the articles reviewed presented enough data to examine the role of culture. This review has shown that while cultural continuity may very well be important, its effects in relation to IYS are more complex than perhaps originally believed.

Nasir, B.; Hides, L.; Ranmuthugala, G.; Nicholson, G.; Black, E.; Gill, N.; Kondalsamy- Chennakesavan, S.; Toombs, M. (2016). The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: A systematic review. BioMed Central Psychiatry, 16, 357-365.

The authors searched for research articles about gatekeeper training programs that target Indigenous populations in any country, published between 2000 and 2016. Their systematic review process led them to 2609 articles, from which six fully met their criteria for inclusion. These articles featured in detail five gatekeeper training studies which took place in Canada, the U.S., and Australia.

The analysis of these articles focused particularly on the cultural appropriateness of the gatekeeper training, as well as its effectiveness. They found support for the effectiveness of gatekeeper training, but this was measured primarily in terms of changes in attitude, not behaviour. Importantly, among the studies reviewed was one randomized control trial, which found no significant evidence of effectiveness of gatekeeper training. Notably absent from the studies reviewed were those that evaluated effect of gatekeeper training on suicide attempts, and only one adapted the model to be culturally informed and tailored.

The authors conclude that uncontrolled evidence suggests gatekeeper training could be potentially useful for suicide prevention in Indigenous communities, but that a) it needs to be tailored to their target audience and b) more research on the effectiveness of culturally adapted approaches is needed.

Ridani, R.; Shand, F.; Christensen, H.; McKay, K.; Burns, J.; & Hunter, E. (2015). Suicide prevention in Australian aboriginal communities: A review of past and present programs. Suicide and Life-threatening Behaviour, 45(1), 111- 140.

This review of aboriginal suicide prevention programs in Australia focused on those published between 1998 and 2012. Forty-six articles were closely inspected. Most programs focused on youth or the entire community. There were a diversity of programs including (but not limited to) training, workshops, and creative expression. Most were run by Aboriginal organizations, often with partnerships with external organizations.

A major shortcoming that was identified was evaluation: “the majority of programs (63%) made no mention of program outcomes or had only process evaluations … twenty-eight percent of evaluated programs made mention of observed changes in suicide rates over time … Only one program … measured and reported reduced suicidal ideation.” (p. 136).

Thus, the main recommendation of this review is to evaluate outcomes. This was identified as particularly important because there is not yet a clear understanding of what other communities are doing, and what works well. Culturally appropriate research methods are advocated.

Studies that Support Community Wide Interventions

Alcantara, C. & Gone, J. (2007). Reviewing suicide in Native American communities: Situating risk and protective factors within a transactional-ecological framework, Death Studies, 31(5), 457-477.

The authors begin by discussing the crises of suicide epidemics, pointing to the very real limitations of trying to predict suicide before it happens, and the paradoxical requirement that ‘treatment’ for suicide occur before the incident itself. They then outline a number of risk and protective factors that can hopefully aid in reaching people who most need support. They draw particularly on a transactional-ecological framework, which “targets the interactions between individuals and their environments along developmental trajectories toward negative outcomes” (p. 460). This approach rejects both victim-blaming and a disease prevention model of intervention. Instead, it focuses on broad-based conditions that might lead to (or prevent) any number of undesirable outcomes (such as substance use, suicide, school failure) without having to necessarily predict any one of them.

In relation to suicide prevention, this approach aims to restore healthy trajectories with young people, without having to target (or blame) and particular individuals. It generally “avoids person-focused interventions altogether, emphasizing transaction-focused and even environmentally focused interventions” (p. 465). Detailing risk factors and protective factors for suicide, the authors then suggests potential interventions informed by this framework which generally involve establishing and strengthening protective factors.

Allen, J., Hopper, K.; Wexler, L.; Kral, M.; Rasmus, S.; Nystad, K. (2014). Mapping resilience pathways of Indigenous youth in five circumpolar communities. Transcultural Psychiatry, 51(5), 601-631.

This study features learning from five circumpolar communities, specifically focusing on “stressors that make for difficult passages and the resilience processes that safeguard transition into adulthood” (p. 602). The narratives shared shed insight on how youth experiences of resilience remain grounded in traditional cultural practices, while also integrating “new emergent strategies” (p. 602).

Twenty youth were interviewed at each of the five sites, and shared their stories of transition to adulthood. Youth ranged in age from 11 to 19, and attempts were made to equally represent genders. Rather than generalizing on the basis of these varied stories from diverse perspectives, they were instead ‘mapped’ for “locally salient themes” (p. 619). This honours the fact that meanings are made in context and in relation.

This work is based on a participatory action research process, deeply informed by longstanding research relationships and designed collaboratively. It is part of a longer-term process of building community-based research capacities, and contributing to a body of knowledge grounded in community and culture. Resilience, in this work, is understood not as a psychological construct but in ecological terms and grounded in Indigenous worldviews: it is system-oriented, recognizing individual resilience in complex relation with many other factors, taking social determinants of health as key to understanding resilience.

Allen, J.; Mohatt, G.; Ching Ting Fok, C.; Henry, D.; & People Awakening Team. (2009). Suicide prevention as a community development process: Understanding circumpolar youth suicide prevention through community level outcomes. International Journal of Circumpolar Health, 68(3), 274-291.

This article takes as its starting place the fact that since community-based models have become increasingly prominent in prevention, then “outcomes from circumpolar suicide prevention programs might be more completely understood at the community level” (p. 274). This paper specifically looks at a “prevention program for rural Yup’ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through chances at the community level” (p. 274).

In this particular study safety, enforcement of alcohol prohibition, role models, support and opportunities for youth were assessed as community protective factors. Participants included key informants, youth, and adults (a parent or adult sponsor of the youth). There were a range of tools used, including Community Readiness Assessment pre- and post-tests (completed at different rates by the range of participants) spaced approximately one year apart. Other tools included: the Adult Community Protective Factors Behaviours Scale, the Youth Community Protective Factors Scale, and more.

Primary findings suggest that the intervention led to an increase in community readiness and protective factors. The small sample size does not hold statistical significance, but the authors recognize this as a feasibility study which, when taken in the context of other research, suggests potential for positive outcomes beyond this community as well.

Andersson, N. & Ledogar, R. (2008). The CEIT Aboriginal youth resilience studies: 14 years of capacity building and methods development in Canada. Pimatisiwin, 6(2), 65-88

This article focuses on the methods used in a large scale community based research project about resilience in Aboriginal communities. Partnering communities were involved in the design of the project, so it looked different in each place – and community members were researchers on the team, though this involvement also differed from community to community. In each case, interviewers were nominated by their own community members (again, through varying processes). A significant piece of learning from this project involved the importance of hiring and training Aboriginal research coordinators as well.

A challenge encountered was due to the limitations of the instruments available at the time to measure resiliency. Many of them focused more squarely on individual qualities, and were not “ideal Aboriginal resilience tools” (p. 67). Changes were thus made, to include considerations of such things as: “sense of coherence, spirituality, experience, and enculturation” and pride in one’s heritage (p. 68). Findings also included a number of external resilience factors such as feeling supported, the role of peers, parenting support, and the wider community. This research specifically looked at resilience in relation to particular risks. In some cases an association was found, and in others it was not – thought the authors are clear that this does not mean one does not exist. A strong association was found between peer support and resilience.

Before concluding the authors highlight a “negative side” to their findings (p. 76): In places were few of the external factors exist (such as peer, parental, and community support), this can lead to a “negative social capital” (p. 76) in the face of which it can be quite difficult for young people to experience resilience. This points to the importance of system-level change.

Chino, M. & DeBruyn, L. (2006). Building true capacity: Indigenous models for Indigenous communities. American Journal of Public Health, 96(4), 596-599.

This commentary speaks to how building community capacity and empowerment can contribute to eliminating health disparities among populations – particularly between Indigenous and non-Indigenous people. Importantly, the authors identify that the frameworks upon which capacity-building and empowerment initiatives are built need to reflect Indigenous knowledge and ways of being, rather than importing western models. “Indigenous people need to define and develop not only health care services but also the underlying theoretical frameworks and strategies” (p. 596).

While the concepts of capacity-building and empowerment acknowledge the importance of integrating local knowledge, the conceptual frameworks themselves have rarely been specifically developed by or with Indigenous people. This is a real problem, because “Western definitions of success and the expected benefits to the community differ greatly from tribal expectations and definitions” (p. 596).

Addressing this effectively requires processes that engage Indigenous communities on their own terms, with their own frames of reference. It also requires allowances of time for this to be accomplished and maintained; much more time than dominant processes and funding structures often provide for. It requires a willingness to work in ways that are not linear, and lead to mutual learning and transformation. The paper concludes by offering a working example of an Indigenous framework.

Chung-Do, J.; Goebert, D.; Bifulco, K.; Tydingco, T.; Alvarez, A.; Rehuher, D.; Sugimoto- Matsuda, J.; Arume, B.; & Wilcox, P. (2011). Hawai’i’s Caring Communities initiative: Mobilizing rural and ethnic minority communities for youth suicide prevention. Journal of Health Disparities Research and Practice, 8(4), 108-123.

This article proposes a model for youth leadership development, which is utilized by the Hawai’i’s Caring Communities Initiative (HCCI). This model trains and supports youth and community members in a community-based approach to suicide prevention. It is not only focused on indigenous youth, but rural and ethnic minorities.

This initiative was one component of state-wide efforts to support at-risk youth. The university partnered with community organization (through the state) and worked from a collaborative and strength-based approach, integrating “evidence-based” approaches to suicide prevention (p. 111). Building on previous work, they developed a youth leadership model “that focused on a combination of training, relationship-building, empowerment, and implementation of community awareness projects” (p. 112). Community partners played an active role in shaping the activities in the initiative – which aimed to leverage the strengths within each community and actively involve youth and adult mentors.

By way of illustration, the article the focuses on one example of this initiative: Kaua’i Leaders Against Suicide (KLAS). Methods for evaluation are shared, and the project was deemed successful. The authors discuss a number of factors that may have contributed to its success: prioritizing relationships, increasing self-efficacy through mentorship, taking sufficient time up front to establish these relationships and group identity, providing plenty of communication and face-to-face opportunities to nurture university and community partnerships, building connections among projects across the island (which helped strengthen each individual community project as well), and having a strong coordinator who collaborated well with youth and was connected to the community.

Cousins, J. B.; Descent, D.; Kinney, M.; Moore, M.; Pruden, J.; Sanderson, K.; Wood, I. (2010). National Aboriginal Youth Suicide Prevention Strategy: Multiple Case Study of Community Initiatives. Ottawa, ON: Centre for Research on Educational and Community Services. Prepared for: First Nations and Inuit Health Branch, Health Canada.

This 45-page document reports on four of the NAYSPS-funded community projects, located in Alberta (Hobbema), Saskatchewan (Battlefords Tribal Council Indian Health Service), Quebec (Uashat mak Mani-utenam) and Labrador (Nunatsiavut). It does so by way of case study, with the two goals of a) understanding the impact of the projects on communities/youth, and b) understanding strengths and weaknesses of implementation to help inform improvements.

The report gives some background information of the NAYSPS, then explores each case study individually before doing a cross-case analysis. Some of the findings of this analysis reflect the intentions of the NAYSPS, while others reflected unintended implications (both positive and negative). General findings included: “Relationship building and support networks; Optimism / hope / confidence building; Protective factor augmentation; Risk factor reduction; Cultural connections; Openness/willingness to talk about suicide; Community support and engagement” (p. 18). These showed up in different ways, but were evident outcomes from each community initiative. The authors also note that a commonality among each initiative was its emphasis on nurturing protective factors, rather than confronting risk factors.

There were also emergent themes related to practices that showed promise of effectiveness. These themes were: “Multidimensionality of programs and program contexts; Intervention design features; Cultural adaptations; Cross boundary cooperation; Evaluation and inquiry activities; Resourcing; and Gender issues” (p. 32). The report concludes by addressing implications for program practice and policy, such as: ensuring the Strategy has the resources (financial and human) to be sustainable over the long-term; supporting the capacity to integrate ongoing research of initiatives; ensuring direct training of youth and others continues to be part of the strategy; and providing opportunities for broad-based training.

Cwik, M.; Tingey, L.; Maschino, A.; Goklish, N.; Larzelere-Hinton, F.; Walkup, J.; & Barlow, A. (2016). Decreases in suicide deaths and attempts link to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012. American Journal of Public Health, 106 (12), p. 2183-2189.

The White Mountain Apache Tribe “created a unique community surveillance system to track and triage suicide deaths, attempts, and ideation that has been used to illustrate differences between their tribe’s suicide rates and those reported” nationally (p. 2183). To build on this work, they received several grants to deliver a comprehensive youth suicide prevention program.

This program includes universal activities, which coordinate local agencies and raise awareness. It includes selected programming that identifies and supports at-risk youth. And it includes indicated interventions that specifically support youth who were exhibiting suicidal behaviours. This article draws on data gathered through the community surveillance system (called ‘Celebrating Life’) to report on changes in suicide rates between 2001 and 2012, and consider the impacts of these interventions.

Overall, there was an approximately 38% decrease in Apache deaths by suicide, while national suicide rates remained stable. The age groups with the greatest decrease in suicide death rates were 1) ages 25 to 34 and 2) ages 20 to 24. Suicide attempts also decreased. This research shows that the surveillance system has been impactful, and suggests such a “multitiered public health approach can have measurable effects in high-risk groups” (p. 2186).

For all ages, alcohol seemed to be a factor in the majority of cases, which needs to be examined further. Interpersonal conflict was also a common factor (ie. fights with partner or parents), and might be explored in relation with alcohol consumption. One concerning finding was that the rates actually went up for youth between 10 and 14. Similarly, women – and especially mothers – were also at increased risk. Reasons for these trends are inconclusive.

Harder, H.; Holyk, T.; Russell, V.; & Klassen-Ross, T. (2015). Nges Siy (I love you): A community-based youth suicide intervention in Northern British Columbia. International Journal of Indigenous Health, 10(2), 21-32.

This article reports on a project that took place among the Carrier Sekani First Nations of northern British Columbia. “The suicide prevention research project described in this paper promoted Carrier systems as the core intervention strategies”, including the development of a resource manual and ‘culture camps’ (p. 22). The project was a partnership between Carrier Sekani Family Services (CSFS) and UNBC, with funding from CIHR, but relied on a Leadership Advisory Council (LAC) consisting of Elder and youth representatives from 11 communities to guide it at every step. The project used a community-based participatory action research approach.

130 youth between the ages of 13 and 25 were recruited to participate in culture camps. (Pre- and post-camp surveys and tests for depression, hopelessness, self-esteem, and suicide ideation were administered). The suicide awareness and prevention manual that was used was developed in partnership with the LAC, who “decide that the training and resulting manual should be organized around eight strong Carrier Sekani values: Respect, Compassion, Wisdom, Responsibility, Caring, Sharing, Harmony, and Balance” (p. 25). Interviews and focus groups took place to create qualitative data.

Findings demonstrate enriched connections with culture and Elders, and an enhanced sense of belonging, pride, and identity. Participants also expressed that a deeper experience meaning was brought to their lives. In terms of challenges, the authors acknowledge that the deep commitment to community engagement comes with a financial cost. Another tension was around the balance of Indigenous and Western epistemologies. A third challenge is the fact that Aboriginal communities are diverse, and there can be a tendency towards generalizing when it comes to research findings. This, and artificially ‘indiginizing’ and applying western approaches to suicide prevention, must be actively resisted.

May, P.; Serna, P.; Hurt, L.; & DeBruyn, L. (2005). Outcome evaluation of a public health approach to suicide prevention in an American Indian tribal nation. American Journal of Public Health, 957), 1238-1244.

First, the authors speak to the importance of a population-based approach to suicide intervention (in contrast with an approach that focuses on individuals) in the United States. While a number of such approaches do exist, particularly among American Indian/Alaska Native populations, there is little research evaluating these efforts.

To address this, they focus on one particular initiative: a model Adolescent Suicide Prevention Project implemented in one community. The authors outline how it was developed, and the various program components. A lot of attention was paid to integrating a range of community-level responses, and to collecting data at every stage (including but not limited to program evaluations and rates of suicidal behaviors). Data was tracked over time, evidencing “a steady reduction in suicidal gestures and attempts … throughout the course of the program” (p. 1240).

The article highlights a number of lessons learned. First, suicide prevention should not focus on modifying problematic behaviours, but rather on alleviating root causes. Second, community involvement must be part of the process from the very beginning (including design). Third, flexibility is essential. This means tracking progress and making changes along the way.

Rasmus, S.; Charles, B.; & Mohatt, G. (2014). Creating Qungasvik (A Yup’ik intervention ‘toolbox): Case examples from a community-developed and cultural-driven intervention. American Journal of Community Psychology, 54, 140-152.

This paper shares the process undertaken in two communities in southwestern Alaska to develop the Qungasvik, which is a toolbox promoting reasons for life and sobriety among youth. “The Qungasvik manual represents the results of a community based participatory research intervention development process grounded in culture and local process, and nurtured through a syncretic blending of Indigenous and Western theories and practices” (p. 140). The name Qungasvik means ‘toolbox’ and is a meaningful name because this resource “contains tools to help Yup’ik people find their own answers and approaches to problems threatening their communities and youth, including the problems of suicide and alcohol abuse” (p. 141).

Importantly, it does not consist of solutions or interventions that are replicable. Rather, it consists of processes that can be supportive for communities and their young people to derive their own solutions and resources. It is “culturally-grounded”, which does not mean connected to an imagined passed, but rather emergent from existing structures, theories, and practices (p. 141). It draws from indigenous and post-colonial frameworks, but does not see these as synonymous. It is also not as simple as taking “the best of both worlds”; rather it is about a “collapse of dualities” that can only occur when community members determine what is and isn’t meaningful in the process (p. 141).

In terms of process, it is significant to note that this was a community-initiated process, with researchers coming in by invitation. Secondly, it built on existing local traditions, resources, and infrastructure, as well as prior relationships with the research organization. The existing infrastructure provided the settings for the research process. All of these factors are understood to have contributed to its success. The article shares case examples of the development of three modules, as illustrations of the collaborative process undergone.

Wexler, L.; Gubrium, A.; Griffin, M.; & DiFulvio, G. (2013). Promoting positive youth development and highlighting reasons for living in Northwest Alaska through digital storytelling. Health Promotion Practice, 14(4), 617-623.

The project featured in this article involved youth from 12 villages, and generated approximately 566 digital stories by 432 people. Facilitators traveled to each community once a year for four years to offer a workshop. Each of the 39 workshops that took place culminated in a community showing, to which participants were encouraged to invite friends and family members. Additionally, participants were encouraged to share their stories on the website (and most did) – which has seen a lot of activity.

The digital stories emerged as ‘hope kits’, connecting young people with their reasons for living. In surveys and interviews, the participants expressed that the process of creating them was also significant in enabling them to represent themselves, their lives, and their relationships in positive ways. This is particularly important for Native Alaskans, whose identities, self-esteem, and self-efficacy have been negatively impacted by the cultural disruption caused by colonization, assimilation, and racism. These are all linked to indigenous suicide and substance abuse.

The project became increasingly popular over the four year period. Survey feedback was overwhelmingly positive, and participants found the experience meaningful. In terms of primary prevention purposes, the process of reviewing old photos and recalling good times and relationships “serves as an affirmative process for life reflection” (p. 620). Additionally, “digital stories served as mementos for participants to emphasize what was going well in their lives and especially to publicly represent the positives in their lives” (p. 621). Representing strengths and achievements in their digital stories, as well as the achievement of creating the digital stories, were significant. Not only were important relationships highlighted in the stories themselves, but the process of sharing them (publically or privately with significant others) contributed to “strengthening important relationships, particularly intergenerational ones” (p. 621). Sharing to a wider audience online was also important.

Wexler, L.; McEachern, D.; DiFulvio, G.; Smith, C.; Graham, L.; & Dombrowski, K. (2016). Creating a community of practice to prevent suicide through multiple channels: Describing the theoretical foundations and structured learning of PC CARES. International Quarterly of Community Health Education, 36(2), 115-122.

This article is about PC CARES: Promoting Community Conversations About Research to End Suicide, which consists of monthly learning circles. In particular, this article looks at how PC CARES integrates “popular education theories, ‘community of practice’ strategies, and scientific literature” (p. 116).

Its commitment to decolonization means PC CARES prioritizes “postcolonial forms of therapeutic interview” (p. 116) and reflects “relational, familial, social, and spiritual dimensions of selfhood more than decontextualized, expert-driven, individualistic, biomedical understandings of distress” (p. 116). It is also community-situated and is grounded in local protocols and practices. In terms of pedagogy, it relies on critically engaged and experiential approaches, linking understanding with action, and with an openness to diverse forms of expression. Finally, it is also a community of practice model, which brings people together around a shared concern. In this case, “the model invites community stakeholders, tribal leaders, rural providers of health and human services, law enforcement, religious heads, and others to come together each month to learn ‘what we know, think, and want to do’ about suicide and suicide prevention” (p. 117). Drawing from adult learning theory, attention is paid to how content is delivered, how dialogue is facilitated, and how the learning environment is structured. Local, mostly indigenous facilitators foster an environment where participatory processes can take place. A flexible and responsive approach is prioritized, although a predictable structure frames every gathering. The content of each session varies, but scientific information does comprise some of the knowledge shared in bite-sized pieces during the ‘what we know’ section of the session. Importantly content is also generated by participants themselves in the ‘what we think’ and ‘what we want to do’ sections.

PC CARES has been implemented in six rural Alaskan communities, and was developed in collaboration with local leaders. Pre- and post- data is being collected to assess impact.

Studies that Support Youth Engagement

Bird-Naytowhow, K.; Hatala, A.; Pearl, T.; Judge, A.; & Sjoblom, E. (2017). Ceremonies of relationship: Engaging urban Indigenous youth in community-based research. International Journal of Qualitative Methods, 16, 1-14.

Given that ethical relationships are central to Indigenous community-based research, and that research about youth too often excludes them from this process of relationship building, this paper offers an approach to their meaningful inclusion. It is grounded in Indigenous knowledge and practices, and centers what the authors refer to as “ceremonies of relationship” (p. 1). The authors share several ways indigenous knowledge and spiritual practices can contribute to meaningful research that is not merely an academic, but a sacred process.

Given that research has often been part of processes of colonization, the shift not only to collaboration, but to the mindful centering of Indigenous knowledge and relationships in research is very important. The specific project outlined in this paper is called ‘The Youth Resilience Project’ and took place primarily in inner-city neighbourhoods of Saskatoon, Saskachewan. The research team was diverse, and positioned the youth themselves as co-researchers.

They employed a “two-eyed seeing approach” (referencing Mi’kmaw Elders Albert and Murdena Marshall) to not only incorporate Indigenous and western ways of knowing, but to use them together to generate new ways of thinking and doing (p. 5). When working this way, the emphasis on process (from the lens of Indigenous collaborators) was made apparent, thus informing the approach to research that was developed. Particularly as it relates to youth engagement, this process included the following:

  • “A conversational or talking circle method” which is inherently relational (p. 5). This necessitated attention to the cultivation of safe spaces, grounded in trust, transparency, caring, and honesty.
  • Honouring “community ethics and cultural protocols” (p. 6). This meant (at a minimum) respecting the principles of ownership, control, access, and possession, which provide guidance for researchers working with/in Indigenous communities. It also meant ensuring specific cultural protocols are integral to the research process – and what these are will vary greatly depending on the territory where the research is taking place and who is involved. This is also contributes greatly to creating safe and ethical spaces.
  • Engaging the wider community, and actively resisting the imposition of hierarchical relationships when doing so. This, too, is done in creative ways that centre relationships, safety, and cultural protocols.

The intention of the project was to identify sources of resilience for First Nations youth. By centering Indigenous ways of knowing and doing, this project demonstrated the importance of ensuring the process by which research is conducted must be congruent with the stated intensions of the research itself. Through this process, the ways resilience is already being fostered became more visible and accessible to them.

Crooks, C.; Chiodo, D.; Thomas, D.; & Hughes, R. (2010). Strengths-based programming for First Nations youth in schools: Building engagement through healthy relationships and leadership skills. International Journal of Mental health and Addiction, 8,160-173.

This article showcases a range of projects initiated within a single school board aimed at improving relationships and engagement for First Nations youth. The case is made for strength-based programming that is culturally appropriate, particularly for First Nations youth in Canada as it helps to see current negative outcomes as impacts of “the deliberate suppression and elimination of culture and tradition [which] led to multi-generational trauma” (p. 161) rather than an indication of individual pathologies. The projects described in the current article occur within the Thames Valley District School Board of London, Ontario – where there are three First Nations. Young people from these Nations typically enter the TVDSB in either grade 6 or 8.

The first is a peer mentoring project, which connects older students who are connected to school with younger/newer students. The next project is a First Nations Cultural Leadership course offered for credit at the school. The third project is Grade 8 transition conferences: “to prepare senior elementary school students for a successful transition to high school” (p. 165). Evidence has been gathered of increased engagement. Indicators include behavioural, cognitive, and attitudinal. Future efforts will continue to focus on and expand those that are already going well. There will also be efforts to build system capacity to provide stability for these projects.

Crooks, C.; Exner-Cortens, D.; Burm, S.; Lapointe, A.; & Chiodo, D. (2017). Two years of relationship-focused mentoring for First Nations, Metis, and Inuit adolescents: Promoting positive mental health. Journal of Primary Prevention, 38, 87-104.

Cultural connectedness is defined here as “the extent to which individuals are embedded in their cultural group; also referred to as enculturation” (p. 88). Given that this is now widely understood as a protective factor for indigenous youth, the authors report on a study that examines the effectiveness of a particular mentorship program. “The Fourth R is an evidence-based, healthy relationships and violence prevention program that was designed for universal implementation in classrooms” (p. 89). Mentoring is recognized as particularly culturally fitting for Indigenous communities as it supports intergenerational relationships and knowledge transfer.

The current paper reports on a mixed-methods longitudinal study to evaluate the impacts of one or two years of program participation, particularly as it relates to positive well-being as students transition from elementary to secondary school. It was found to have positive effects on “self-confidence, interpersonal relationships, coping/conflict resolution skills, and cultural connectedness” (p. 100). Interestingly, the qualitative data indicated this after one year of participation, while the quantitative data only showed it after two years. The “culturally sensitive and affirming space” created by the program supported students to more deeply explore their cultural identity, which research shows to be significant for identity formation (p. 100) and resilience.

Fortier, J.; Chartier, M.; Turner, S.; Murdock, N.; Turner, F.; Sareen, J.; Afifi, T.; Katz, L.; Brownell, M.; Bolton, J.; Elias, B,; Isaak, C.; Woodgate, R.; Jiang, D. (2018). Adapting and enhancing PAX Good Behavior Game for First Nations communities: a mixed-methods study protocol developed with Swampy Cree Tribal Council communities in Manitoba. BMJ Open, 8, e018454. doi:10.1136/bmjopen-2017-018454.

The Good Behaviour Game (GBG) reduces a number of problematic outcomes for youth, and is one of the few evidence-based approaches identified to reduce suicidal behaviours in youth. It is school-based, is implemented by teachers, and takes place during regular classroom time. Its goal is to “enhance students’ self-regulation and behaviour self-management” but it is also seen to enhance peer relationships, which may account for the associated positive health outcomes (p. 2).

It has had positive results internationally and with diverse populations, including many First Nations in Manitoba. However, there is little known about its cultural safety, appropriateness, and effectiveness with First Nations youth, so the current study examines that. Given that First Nations communities “continue to experience physical, emotional and spiritual ill health because of historical traumas and current realities”, this is important research (p. 2). The study aims to see if GBG contributes to mino pimatisiwin (the good life) and evaluates it by integrating Indigenous and western approaches.

The current article outlines the collaborative research process used to assess whether the GBG can be effectively and ethically adapted for First Nations children and youth.

Jacono, J. & Jacono, B. (2008). The use of puppetry for health promotion and suicide prevention among Mi’Kmaq youth. Journal of Holistic Nursing, 26(1), 50-55.

This article explores an initiative that took place on some of the Mi’Kmaq First nations reserves on Cape Breton Island. The initiative combined traditional aboriginal knowledge with western science knowledge “in developing holistic strategies for improving the mental health of the youth on these reserves” (p. 50).

The authors outline puppetry as a particular intervention that can bolster wellbeing for young people in the following ways: 1) Mentored by elders, the natural materials with which the puppets are made are gathered from the land. This process itself is significant in relationship building between generations and between the people and the land. 2) “Researching, scripting, and presenting culturally relevant plays using these puppets” (p. 53) puts performers and viewers in close contact with Elders – traditional knowledge keepers – and maintains the important tradition of oral storytelling. 3) The content of the particular stories being performed by the puppets contain important teachings about ethical ways of being in relation to others.

There has been no formal data analysis or evaluation of this project, but the implications for holistic nursing are presented, particularly focusing on incorporating culturally relevant puppet play in a range of settings.

Potvin-Boucher, J. & Malone, J. (2014). Facilitating mental health literacy: Targeting Canadian First Nations youth. Canadian Journal of Counselling and Psychotherapy, 48(3), 343-355.

While acknowledging the diversity among First Nations youth, the authors outline some of the commonalities that exist among a range of First Nations worldviews, ways of teaching and learning, spiritual practices, and cultures. Key recommendations for tailoring mental health literacy programs for First Nations youth include “appropriate development or adaptation of programming and cultural sensitivity training for those who administer” the programs (p. 348). Importantly, programs that are “developed and applied locally by FN people” are more effective than generalized programs that are adapted (or applied as is) (p. 348). These authors outline four specific principles suggested by Gone (2004): cultural awareness on the part of the program facilitator, individualization of learning within the program, community collaboration, and ongoing program evaluation.

This article does not speak about suicide in isolation, but sees it as related to other negative outcomes (such as substance use and school dropout). Ongoing youth engagement in mental health literacy programs is seen to alleviate these negative outcomes, but integration of meaningful cultural content in these programs for FN youth is seen as essential. One way to do this is to recognize the importance of participating in cultural practices and getting out into the community and on the land – mental health literacy programs need not take place separately from community life. They offer the example of a peer mentorship program to support these points. Additionally, the authors argue that “a precursor to fostering identity and pride is gaining an understanding of history and context” (p. 349). This moves the conversation from engagement to empowerment, which is argued to be critical for resiliency. Again, specific examples are provided to demonstrate that not only does building programs in culturally relevant ways enhance engagement, but it also increases resiliency and positive outcomes for First Nations youth.

Articles that Address System-Level Change

Gerlach, A. J.; Browne, A. J.; Elliot, D. (2017). Navigating structural violence with Indigenous families: The contested terrain of early childhood intervention and the child welfare system in Canada. The International Indigenous Policy Journal, 8(3)

Retrieved from: http://ir.lib.uwo.ca/iipj/vol8/iss3/6

The child welfare system in Canada is part of the colonizing infrastructure that leads to oppression and marginalization of Indigenous families. This paper reports on a qualitative research study in British Columbia that explored the impact of Aboriginal Infant Development Programs (AIDPs) on outcomes for Indigenous children and families.

Findings suggest that AIDPs help mothers and children “make sense of what’s happening” (p. 1) and (through meaningful relationships) counteract feelings of judgements of being “bad parents” (p. 2). However, findings also indicate that AIDP workers sometimes feel limited in their capacity to offer meaningful and transparent support because of being pulled into a reactive and crisis-driven child welfare system. Perhaps most troubling was the finding that meaningful and supportive relationships were often undermined that rather than supporting families, AIDP workers were serving as “the eyes of the ministry” (p. 9).

The authors recommend more attention to “understanding Indigenous families’ experiences of the contemporary child welfare system within the broader socio-historical contexts of their lives” (p. 11). They highlight the significant role AIDP workers can and do play to counter pathologizing and racialized discourses about Indigenous women, and highlight this as a powerful act of resistance. This leads to a discussion of structural violence, and recommendations for both “a policy framework and targeted funding for family preservation and support services” (p. 12).

Goodkind, J.; Ross-Toledo, K.; John, S.; Hall, J.; Ross, L.; Freeland, L.; Coletta, E.; Becenti-Fundark, T.; Poola, C.; Begay-Roanhorse, R.; & Lee, C. (2010). Promoting healing and restoring trust: Policy recommendations for improving behavioural health care for American Indian/ Alaska Native adolescents. American Journal of Community Psychology, 46, 386-394.

The policy recommendations presented in this article are based on a comprehensive review of the literature that brought to light seven major behaviour health disparities and challenges (including but not limited to youth suicide) negatively impacting many American Indian and Alaska Native nations and tribes. The disparities and challenges are: “(1) high levels of violence and trauma exposure and traumatic loss, (2) past and current oppression, racism, and discrimination, (3) underfunded systems of care, (4) disregard for effective indigenous practices in service provision, policy, and funding, (5) overreliance on evidence-based practices, (6) lack of cultural competence among systems of care and providers, and (7) barriers to care” (p. 386).

These disparities were then traced to seven focal causes of these disparities, which are systemic in nature and outlined in detail by the authors. Based on these causes, concrete policy recommendations are made: to increase the capacity to utilize and compensate traditional healers, to provide better infrastructure funding for primary care providers, to value “practice-based evidence” that is relevant to communities (p. 389), to acknowledge and address the multiple stressors in the lives of AI/AN youth, to support and fund programs that link prevention with treatment, to “create alternative licensing and credentialing for Native service providers” (p. 390), and to issue a federal apology. These recommendations are discussed in relation to the evidence, and to each other.

Hallett, D.; Chandler, M.; & Lalonde, C. (2007). Aboriginal language knowledge and youth suicide. Cognitive Development, 22, p. 392-399.

This study hypothesizes that community-level efforts to preserve language serve as a marker of cultural continuity that proves to be associated with youth suicide rates. The authors begin by making the case for the significance of language in terms of cultural survival and community measures of health and well-being, by consulting literature from around the world. Then they focus on British Columbia in particular, which “has the greatest linguistic diversity, one of the smallest language populations, and the largest number of endangered languages of any Canadian province” (p. 394).

In this study, the authors draw data from previous studies (their own and others) which relied in part on the 1996 national census and looked specifically at 152 of the province’s 195 bands (though due to the small size of many communities, some were clustered for the purposes of analysis. “Results indicate that those bands with higher levels of language knowledge (i.e. more than 50%) had fewer suicides than those bands with lower levels” (p. 396). Through their analysis, these authors conclude that “at least in the case of BC, those bands in which a majority of members reported a conversational knowledge of an Aboriginal language also experienced low to absent youth suicide rates. By contrast, those bands in which less than half of the members reported conversational knowledge suicide rates were six times greater.” (p. 398).

LaFrance, J. & Nichols, R. (2010). Reframing evaluation: Defining an Indigenous evaluation framework. The Canadian Journal of Program Evaluation, 23(2), 13-31.

This article elaborates on the development of an Indigenous framework for evaluation, which is grounded in Indigenous ways of knowing while meeting the demands of western evaluation practices. Due to harmful and exploitative precedents, research and evaluation are not often popular in Indigenous communities. Thus, it was vital that the development of this framework set a different precedent. In particular, it aimed to meet the call for “usefulness, restoration, preservation, and sovereignty” and the insistence that the work “be grounded in Indigenous epistemologies, responsive to cultural values, and embraced by the communities that it is intended to serve” (p. 16).

After outlining the consultation process and key learning, the authors describe the framework, which is grounded in four key values: “a) being a people of a place, b) recognizing our gifts, c) honouring family and community, and d) respecting sovereignty” (p. 22). They also point to three types of knowledge (traditional knowledge, empirical knowledge, and revealed knowledge). Taken together, these can lead to more comprehensive evaluative processes that “value subjective experience as well as objective data” and ensures knowledge is always generated with the purpose of “contributing to the health and well-being of the world” (p. 27).

Lawson-Te Aho, K. & Liu, J. (2010). Indigenous suicide and colonization: The legacy of violence and the necessity of self-determination. International Journal of Conflict and Violence, 4(1), 124-133.

This article draws on Indigenous – and specifically Maori – wisdom in relation to youth suicide. It is based on this premise, poignantly stated by the authors: “development with Maori at the helm of a culture-appropriate process may actually negate the need for suicide prevention. The thesis is that when Maori youth are engaged in their own development and reclaiming their own cultural identity, it gives them purpose, meaning, and thereby a will to live” (p. 125).

The foundation of this understanding is a concept called whakapapa, which highlights kinship relationships in all aspects of human experience, social organization, and identity. By referencing the “clear evidence of the traumatizing impacts of colonization” (p. 127), the authors make explicit the link between self-determination and wellbeing for Indigenous youth. Outlining a path forward for Maori development, they project that it is in fact with these structural, systemic, and political changes that youth suicide will be effectively addressed – not individualized interventions.

Payne, H.; Steele, M.; Bingham, J.; & Sloan, C. (2017). Identifying and reducing disparities in mental health outcomes among American Indians and Alaskan Natives using public health, mental healthcare and legal perspectives. Administration and Policy in Mental Health, doi: 10.1007/s10488-016-0777-7.

This article draws from three perspectives – public health, legal policy, and mental healthcare – and presents evidence-based recommendations to help reduce the gaps in mental health outcomes impacting American Indians and Alaskan Natives (including but not limited to youth suicide). Each of the three perspectives is outlined in detail, providing a deeper understanding of the disparities impacting indigenous youth.

The recommendations are based on an integration of the learning from public health, legal policy, and mental healthcare taken together. They include: increasing funding for assessment and reduction of mental health disparities, providing support for culturally-based interventions, and ensuring funding practices are modelled on principles of tribal self-determination.

Strickland, J. & Cooper, M. (2011). Getting into trouble: Perspectives on stress and suicide prevention among Pacific Northwest Indian youth. Journal of Transcultural Nursing, 22(3), 240-247.

The perspectives of young people are often missing from the research. “In this descriptive, ethnographic study in a Pacific Northwest tribe, the goal was to gain an understanding of the life experiences of the youth” (p. 240). Data was collected by way of three focus groups over a two year period, as well as “observations in the schools, in the homes, and community events” (p. 242). All youth who participated in this study were considered ‘at risk’ of suicide.

The stories shared by youth who participated in this study often revolved around ‘getting into trouble’ – with school, police, and family. “Being ‘Indian’ put them at risk” (p. 243), and the strategies they developed to cope with this often led to more trouble. “They hoped for strengthening of cultural values and activities, economic development, tribal unity, and an opportunity to be able to make their contributions to the tribe” (p. 246).

The authors claim this study supports existing research and “the importance of system-level intervention aimed at strengthening the culture and addressing social injustice” (p. 246).

Studies that Demonstrate Creative Partnerships

Allen, J.; Mohatt, G.; Beehler, S.; & Rowe, H. (2014). People awakening: Collaborative research to develop cultural strategies for prevention in community intervention. American Journal of Community Psychology, 54, 100-111.

“The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities” (p. 100). The People Awakening project aims to address the limitations found in the literature – discussed in detail in this article.

This article then outlines key elements of the process, the conceptual models, and the implications of this participatory research project. Of particular importance is the fact that the theories that inform this work are culturally embedded, and the relational process of the work itself is thus understood not as a means to an end, but as part of the intervention. The project is described as culturally-driven, not just culturally-embedded. A guiding model for collaboration – which allows for and invites emergence – is also outlined by the authors.

Finlay, J.; Hardy, M.; Morris, D.; & Nagy, A. (2010). Mamow Ki-ken-da-ma-win: A partnership approach to child, youth, family and community wellbeing. International Journal of Mental Health and Addiction, 8, 245-257.

This paper features an initiative called Mamow Sha-way-gi-kay-win: everyone searching for the answers together. This is proposed as a model for First Nations and non-aboriginal partnerships that are “healing, enduring, and facilitating of resource exchange and development” (p. 246). It does not centre suicide prevention specifically, but relational and collaborative approaches to addressing community difficulties. The Partnership featured here is a “developing partnership, which was established collaboratively between First Nation Chiefs, Elders, youth and community members, living in 30 remote communities in northwestern Ontario, and 100 individuals and voluntary organizations based in southern Ontario” (p. 246). The idea is that the framework can help communities determine their own starting points for partnerships addressing community wellbeing, based on their unique configuration of these factors.

In a section devoted specifically to youth suicide, the authors draw on Chandler and Lalonde’s work to highlight how addressing social, political, and cultural factors such as those that appear in the framework can help to support initiatives aimed at preventing youth suicide. The reminder that not all First Nations communities share any particular challenge (including high rates of youth suicide) is made explicit here – which is why community-driven interventions are so important. The process so far has been undergone in seven communities, and sharing across communities is seen as an integral component.

Assessments are done in a variety of ways, and capacity building initiatives are generated locally. The conclusion emphasizes that this is an evolution, but the results of assessments and evaluations that have taken place so far are not explicitly presented.

Isaak, C.; Campeau, M.; Katz, L.; Enns, M.; Elias, B.; Sareen, J.; & Swampy Cree Suicide Prevention Team. (2010). Community-based suicide prevention research in remote on-reserve First Nations communities. International Journal of Mental Health and Addiction, 8, 258-270.

Acknowledging that there is not a lot of evidence-based research done on community-based interventions, the authors assert that we need to understand how to better do research in communities. In particular, this article focuses on a collaboration between a university-First Nations tribal organization team and Manitoba First Nations communities: the Swampy Cree Suicide Prevention Team.

The Participatory Action Research project being described is called ‘From risk factors to culturally sensitive interventions’ and involved the community equally at every step of the research. Critical to the success of the project was a pre-existing relationship between some of the researchers and communities. The initial stage of the project was to have Indigenous knowledge guide the direction. A lot of time was also devoted to visiting the communities and relationship building, as well as establishing community liaisons and community advisory councils.

Challenges also exist, including the fact that research has been a means of colonization so First Nations communities in particular may be understandably sceptical. The lessons learned sections spoke to negotiating the differences between Aboriginal and Western approaches to the research process.

Studies that Support Culturally and Sociopolitically Informed Approaches

Barker, B.; Goodman, A.; & DeBeck, K. (2017). Reclaiming Indigenous identities: Culture as strength against suicide among Indigenous youth in Canada. Canadian Journal of Public Health, 108(2), e208-e210.

This commentary explicitly notes that suicide among Indigenous people in Canada results from “the trauma inflicted by colonization in Canada” (p. e208), and as such responses to the historically recent rise in suicidality among Indigenous people must take culture into account. The authors explore the potential of a growing body evidence of “culture as treatment” (p. e208). Acknowledging the general inefficacy of western approaches to suicide prevention in Indigenous contexts, they turn attention to the range of indicators that connect Indigenous peoples’ health with identity and culture.

Culture-as-treatment has been more widely used in addiction treatment settings, but is increasingly being recognized for its value in relation to suicide prevention as well. Importantly, this approach requires a community-based response, and cannot be standardized to be implemented in uniform ways from community to community. “Given the established link between the loss of Indigenous culture and the risk of suicide, cultural reclamation and revitalization may be a critical step toward reducing rates of suicide among Indigenous youth” (p. e209). This statement also makes clear that culture-as-treatment holds a great deal of potential when accompanied by broader, system-level changes.

Chandler, M. & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry, 35(2), 191-219.

There are four empirically supported assumptions that underlie this work: 1) that young people die by suicide more than adults; 2) that those whose cultures are under siege are more likely to die by suicide; 3) that “suicidal adolescents will prove to be uniquely marked by an inability to sustain a sense of self-continuity” (p. 3); and 4) that “First Nations groups characterized by community efforts to achieve a greater sense of cultural continuity will show reduced suicide rates” (p. 3). It is the last two points that are not necessarily commonly understood, and to which the research of these authors have pointed.

Understanding these four points collectively, suicide prevention efforts would look very different. Rather than focusing on the alleviation of individualized and depressive symptoms, they would instead focus on enhancement of self- and cultural-continuity. The theoretical and empirical rationale for the above argument is elaborated fully in the article itself, as are definitions of the various concepts that inform this work.

Clark, N. (2016). Shock and awe: Trauma as the new colonial frontier. Humanities, 5(14), 1-16.

Drawing from her own research and practice with girls, this author highlights the importance of drawing on Indigenous frames of understanding when working with Indigenous youth.

In so doing, she offers a powerful critique of dominant discourses about trauma, which tend to be both individualizing and medicalizing. This approach obscures the political nature of trauma, and the complexities and intersections that actually informed lived experience. This is quite damaging as an individualized understanding of trauma actually contributes to further marginalization of and stigma towards certain populations. She insists that the “current construction of trauma continues to create a colonial subject who requires intervention, support and saving. A focus on trauma as an individual health problem, as in this girls story, prevents and obscures a more critical, historically-situated focus on social problems under a (neo)colonial state that contribute to violence and harm” (p. 2).

In response to this critique, she offers hopeful and pragmatic possibilities based on the fact that “knowledge of how to address violence and wellness in our communities has always existed” (p. 5). Importantly, she notes the fact that early Indigenous activists “did not separate out their activism around tribal rights and water rights from their activism against violence under colonialism” (p. 6). By not only critiquing dominant western approaches to trauma, but deliberately centering Indigenous ways of knowing, resistance, relational spaces, witnessing and truth-telling, and activism, she outlines ‘red intersectionality’ as a promising way forward. She urges us to develop and implement models for addressing trauma that are grounded in Indigenous frameworks.

de Finney, S. (2017). Indigenous girls’ resilience in settler states: Honouring body and land sovereignty. Agenda, 31(2), 10-21.

The author insists that actively politicizing resilience brings it to light in ways that are obscured by (currently dominant) individualized conceptualizations of it. She says, “Given that Indigenous girls and communities have sustained themselves for hundreds of years in a context of ongoing gender-based and sexualised violence, they have demonstrated the most impressive kinds of resilience. Clearly then, when set against pervasive colonial patriarchal rule, psychosocial conceptualisations of Indigenous girls’ ‘resilience’ need to be rethought and repoliticised” (p. 10).

With this as her starting place, she outlines how colonialism and capitalism continue to work together to construct girls, women, and land as property. This has led to many atrocities that devalue certain lives, and contribute to a) violence towards them, and b) the continued systemic dismissiveness towards acts of resistance to this violence. This, in turn, has contributed to the psychologisation of trauma and resilience – locating them within individuals rather than sociopolitical dynamics. By deliberately “depsychologising” resilience (p. 14), this author notes the painful irony that the systems being deployed to address trauma from within a psychological frame of reference are (some of) the very systems that have enacted the violence that led to oppressive realities to begin with.

She then recasts resilience as sovereignty (of body and land), highlighting the point that promoting resilience, then, is about social and political action through resurgence.

Elliot-Groves, E. (2017). Insights from Cowichan: A hybrid approach to understanding suicide in one First Nations’ collective. Suicide and Life-Threatening Behaviour, 1- 12. DOI: 10.1111/sltb.12364

This article reports on part of a larger study “designed to understand how Cowichan tribal members make sense of suicide in relation to contemporary and historical experiences” (p. 3). 21 tribal members were interviewed, and other data were drawn from observation and field notes. The interviews were intended to understand participants’ daily experiences, beliefs related to suicide, and ideas for community-specific responses. Importantly, the researcher is a member of the community in which the research is being conducted.

Findings suggest that there are multiple explanations for suicide in the Cowichan Tribes, and that these include individual and collective level experiences – and an interplay among them. The author evokes both the interpersonal theory of suicide and settler-colonial theory in her analysis of the data. A recommendation suggests that “the interdependent orientation of tribal communities necessitates the development of community-based programming to engage individuals, as well as the collective” (p. 10).

Gone, J. (2013). Redressing First Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5), 683- 706.

Historical trauma (HT) is an important “countercolonial construct” (p. 688) in that it preserves a relational emphasis, focuses on social pathology rather than “broken brains” (p. 688) and makes way for “opportunities for indigenous cultural education and ceremonial participation in service to powerful renewals in tribal identification” (p. 688).

With the stage thus set, the author devotes the remainder of the article to one case study that is part of a broader research project. It takes place at a Healing Lodge on a northern Manitoba Algonquin Reserve. The Healing Lodge overtly identified itself as part of a “cultural renaissance” which promotes “robust Aboriginal cultural identification as a remedy to anomie and its associated ills, such as violence, family dysfunction, and substance dependence” (p. 690).

Specifically focusing on the story of one residential school survivor who attended the Healing Lodge, the author demonstrates how “the legacy of the residential schools for these survivors involves shared disruptions in the psychological, social, and spiritual realms of experience that the concept of HT was intentionally designed to capture and represent (p. 692). The article concludes by contextualizing Diane’s experience and the Healing Lodge she attended in the context of many other similar experiences, making a strong case for “culture-as-treatment” (p. 697) on the basis of this evidence.

Hackett, C.; Feeny, D.; & Tompa, E. (2016). Canada’s residential school system: Measuring the intergenerational impact of familial attendance on health and mental health outcomes. Journal of Epidemiology and Community Health, 0, 1-10.

This is an extensive quantitative study that explores the intergenerational impacts of Residential School attendance. The authors ground their work in the concept of historical trauma as having a particular impact on Indigenous people. They do not limit their examination of intergenerational impacts to relational dynamics between generations as a result of residential school (RS) experiences, but also consider potential biological mechanisms by which these traumatic experiences can be transferred intergenerationally (drawing from epigenetic research) and also psychosocial and community mechanisms.

The findings of this study do indeed point to the fact that for those with a family member who attended RS, “the likelihood of being in worse self-perceived health and mental health, as well as experiencing self-reported mental distress, suicidal ideation and having a suicide attempt in the past 12 months, increases” (p. 8). In terms of practice implications, the authors note that despite this awareness of intergenerational trauma, most interventions still do not center Indigenous health care principles. And in terms of policy implications, they assert that greater awareness of and attention to the “policy legacies of RS” (p. 8) both within and outside of the health care system are needed.

Hatala, A.; Pearl, T.; Bird-Naytowhow, K.; Judge, A.; Sjoblom, E.; & Liebenberg, L. (2017). “I have strong hopes for the future”: Time orientations and resilience among Canadian Indigenous youth. Qualitative Health Research, 27(9), 1330-1344.

This study explores how concepts of time – and particularly an orientation to the future – impact resiliency and particular health outcomes for Plains Cree and Metis youth in an urban Canadian context. There is a large body of research demonstrating a connection “between a future time orientation (FTO) and health and well-being” (p. 1330). When people lack a FTO (and are instead grounded in a present orientation), there seems to be a stronger likelihood of such things as problematic gambling and drinking, and of suicide among youth. This study aims to address remaining questions about relevance of this across cultural contexts, and particularly as it relates to resilience for Indigenous youth.

After outlining their research methods and processes – informed by a commitment to Indigenous protocols and relational accountability” (p. 1333), the authors share some significant findings. One was the fact that youth spoke of distressing concepts (like colonization) and experiences (such as residential schools and the sixties scoop) as being felt presently, not in a distant past. These present-day experiences of historical trauma were exacerbated by ongoing painful experiences, such as overt racism and family violence.

Another significant insight was how the “normalcy of negativity” (p. 1335) in this lives of these youth (due to the distressing experiences noted above) propelled them into an early state of ‘adulthood’, which seemed to thwart their sense of time. It contributed to a sense of loss (of potential childhoods) and to their sense of future as a useful or positive concept.

All of this came together in their lives to create often unpredictable patterns, and a disrupted future orientation. Particularly when responding to crisis, harm, or unpredictability, young people often cope by focusing on the present. This “created a truncated flow of time for many of the youth” (p. 1336).

In light of this learning and on the basis of this research, the authors elaborate on the following recommendation to promote resilience among First Nations youth: nurturing a sense of belonging, developing self-mastery, and fostering cultural continuity. Deliberately incorporating a future orientation to time into practice may support these aims.

Isbister-Bear, O.; Hatala, A.; & Sjoblom, E. (2017). Strengthening Ahkameyimo among Indigenous youth: The social determinants of health, justice, and resilience in Canada’s north. Journal of Indigenous Wellbeing: Te Mauri – Pimatisiwin, 2(3), 76-89.

The foundation for this article is a review of academic writing, published between 2000 and 2016, that focuses on resilience from Indigenous perspectives. Ahkameyimo is a Cree word, loosely translated to ‘resilience’. It is “the act of not giving up, to diligently continue to work at an objective, or to learn from what one is trying to do or accomplish” (p. 77). Recognizing the many barriers Indigenous people continue to face due to a range of social processes most particularly colonization, and the increased risk to further harm caused by these barriers, the authors explore literature that sheds light on how young people in the north have accessed Ahkameyimo.

Insights that emerge from this research include: centering connections with the land, “the dynamic interaction between an individual their culture, and community” (p. 81), and recognizing the whole state of the person in balance (including emotional and spiritual domains). Resilience does involve skills, but is not limited to skills or personal qualities. Traditional practices (such as berry or medicine picking and hunting, as just two examples) were overwhelmingly seen to foster resilience, as they integrate all of the above.

Importantly, the authors also point to the unjust circumstances that require Indigenous youth to demonstrate Ahkameyimo to such an extent, just to get by. Again, drawing on a large body of research, they highlight recommendations that focus on altering these conditions (rather than preparing young people to cope with them in perpetuity). These recommendations include integrating Indigenous perspectives of resilience into programs and policies, and ultimately tackling societal injustice that will alleviate the disproportionate burden on Indigenous young people to be resilient in the face of hardship. In such a society, the focus could be on “the promotion of sohkastwawin, or strength in mind, body, or heart” instead (p. 84).

McCarty, T.; Romero, M.; & Zepeda, O. (2006). Reclaiming the gift: Indigenous youth counter-narratives on native language loss and revitalization. The American Indian Quarterly, 30(1&), 28-48.

This article begins by pointing to the significance of language for identity. While prior to European contact there were an estimated 300-500 indigenous languages in what are now known as Canada and the United States. Today more the 200 of those remain, but only very few of those (16%) have new speakers to pass the language on. The losses this represents are profound, and have more than symbolic impact.

Drawing on a five-year study on the “personal, familial, and academic” (p. 30) impacts of “Native language shift and retention” on young people (p. 30). The authors are explicit that their intentions with this research are to contribute to language reclamation efforts. They interviewed 190 adults and youth at five school-community sites. In addition to these interviews, their research methods included participant observation, questionnaires, and a review of school achievement data.

This article focuses particularly on counter-narratives that emerged in the interviews. The significance of language for a strong sense of identity was apparent in many of the interviews. While language contributed to a strong sense of pride, there were also stories of shame. In many cases, young people knew their language but chose to speak English for this reason. In this community language comprehension was very high, but many people acknowledged a tendency to hide it. This tension between pride and shame is constantly being negotiated (and is informed by ongoing colonizing dynamics). Similarly, there were divergent explanation of how people felt about their language (caring or not caring about it; needing or not needing it). Interestingly, this led to divergent forms of support for young people by adults, based on perceptions about how important language was to them and for their future. In line with this, there were interesting views shared about the value of English (and whiteness) for success in the world. Youth were constantly navigating this with their choices around language, clothing, and more.

By way of recommendations, the authors suggest a strategic marshalling of resources to support language retention amidst these complexities. “Most youth in this study indicated that they value the Native language, view it as central to their identities, want and expect parents to teach it to them … and, in many cases, employ it as a strategic tool to facilitate their learning of English in school” (p. 43).

Philip, J.; Ford, T.; Henry, D.; Rasmus, S.; & Allen, J. (2016). Relationship of social network to protective factors in suicide and alcohol use disorder intervention for rural Yup’ik Alaska Native youth. Psychosocial Intervention, 25, 45-54.

This article features a multilevel cultural intervention for rural Yup’ik Alaska Native youth impacted by suicide and alcohol, with a particular focus on the significance of networks. In the current study, 50 Yup’ik youth from one community participated in a protective measures survey and 57 in a network survey (average age of participants was approximately 15, and there was close to a 50/50 split of male to female). This study was one component of a broader project.

The authors go into great detail around their methodology and approach to analysis, but ultimately significant findings follow: Connections to adults (as opposed to peers) were understood as an important protective factor in relation to family and community but not individual level. Adults included immediate and extended family, Elders, and other community members. This points to “an inherent strength of Alaska Native community life and culture, with family providing for young people a consistently strong social support network” (p. 51). The finding also suggest that “more network density and increased closeness may have a positive impact on family protective factors” (p. 52). The authors assert that “this study provides an example of the utility of protective factors as alternative to risk factor reduction approaches” (p. 53).

Sareen, J.; Isaak, C.; Bolton, S.; Enns, M.; Elias, B.; Deane, F.; Munro, G.; Stein, M.; Chateau, D.; Gould, M.; & Katz, L. (2013). Gatekeeper training for suicide prevention in First Nations community members: A randomized controlled trial. Depression and Anxiety, 30, 1021-1029.

This article begins by introducing the notion of gatekeeper training and the role it has played in suicide prevention. Despite the fact that systematic research has not previously provided evidence of its efficacy, this has been a widely supported approach to suicide prevention.

This article focuses on a randomized controlled trial in which one group of participants experienced ASIST (a form of gatekeeper training) with a particular focus on suicide prevention and the control group experienced a Resiliency Retreat (which did not focus specifically on suicide. The hypothesis was that those who participated in the gatekeeper training would be more prepared to help those at risk of suicide, since the Resiliency Retreat participants did not focus on suicide.

As far as the authors were aware, this was “the first RCT of a gatekeeper intervention in a remote on-reserve First Nations community sample” (p 1025). The main finding was that “the ASIST training did not have a significant impact” on the primary or secondary outcomes of the study (p. 1025). Furthermore, ASIST training “did not increase gatekeeper behaviors over the 6-month followup period” and ASIST trainees “were not more distressed at follow-up” than the control group (p. 1025). However, “there was a trend toward increased SI [suicidal ideation] among ASIST participants compared to those who received the RR [resilience retreat]” (p. 1025).

The findings of this study are not consistent with uncontrolled evaluations that appear in the other literature about gatekeeper training (most of which is not conducted in First Nations communities), but are consistent with the one other RCT the authors found. The one finding that was entirely novel in this study is that about increased suicidal ideation among ASIST trainees. Although the difference in rates of self-reported suicidal ideation did not reach significance, the authors still claim they are concerning, particularly because 5 of the 7 people who reported increased SI were young people. This raises questions about the appropriateness of gatekeeper training for young people. The authors offer several plausible explanations for this finding, none of which can be substantiated with the data from this study.

Snowshoe, A.; Crooks, C.; Tremblay, P.; & Hinson, R. (2017). Cultural connectedness and is relation to mental wellness for First Nations youth. Journal of Primary Prevention, 38, 67-86.

This article begins by acknowledging the systemic oppression that has contributed to poor mental health for many First Nations (FN) youth, while also recognizing that many FN youth are mentally healthy. Their research looks at the connections between culture and mental health among FN youth to examine this disparity. In particular, they use the Cultural Connectedness Scale (CCS) “to organize, explain, and promote a better understanding of the resiliency mechanisms underlying cultural connectedness for FN youth” (p. 70). Previous studies using this tool could identify correlation, whereas the current study explores causation (ie. the direction of correlation).

After outlining the research process (including methods and analysis) in great detail, the authors share some significant outcomes of their study. First, they developed a shortened version of the scale used, which will ease future research. Second, their research findings showed correlation between cultural connectedness and “self-efficacy, sense of self in the present and future, school connectedness, and life satisfaction”, with the causal relationship in the expected direction (p. 76). And third, the findings show that cultural connectedness “has an important role in understanding FN youths’ belief in their ability to complete tasks and reach goals” (p. 77).

Finally, a very important finding emerged in relation to FN spirituality. It was found that spirituality “is important for a cohesive self-concept” and that it “may enable one to extend that conceptualization into the future (e.g. life purpose)” (p. 77).

Saskamoose, J.; Bellegarde, T.; Sutherland, W.; Pete, S.; McKay-McNabb, K. (2017). Miyo-pimatisiwim developing indigenous cultural responsiveness theory (ICRT): Improving Indigenous health and well-being. The International Indigenous Policy Journal, 8(4)

Retrieved from: http://ir.lib.uwo.ca/iipj/vol8/iss4/1

This paper aims to challenge the dominance of western theoretical models to inform research, policy, and practice by putting forward an approach called Indigenous Cultural Responsiveness Theory (ICRT). The authors are explicit about their decolonizing intentions; they “created this model as an overt act of resistance countering settler narratives that seek to hold power and privilege, justifying and reinforcing aggressive assimilative policies aimed at the destruction of First Nation well-being” (p. 2).

Grounded in spirituality and emerging through ceremony and community engagement, the model aims to promote wellbeing for First Nations in Saskatchewan Canada. The three strategies include: restoring First Nations community-based health and wellness systems; centering “mutually beneficial co-existence” as a foundation for engagement between mainstream and First Nations systems, and transforming “mainstream service delivery to become culturally responsive” (p. 2). The recommend that decolonized approaches also be trauma-informed, strengths-based, community engaged, and spiritually grounded.

The article elaborates on the particular historical context of colonization in Saskatchewan, and points to culture-as-intervention as a fitting response. The authors also highlight the role of Indigenous scholarship in fostering community-based approaches. They draw particularly on Ermine’s concept of “ethical space” as a guiding framework for how societies with different worldviews can engage with one another (p. 7). Similarly, the Mi’kmaw concept of “two-eyed seeing” offers possibilities for ethical engagement across differences (p. 8). Other concepts they integrate into their recommendations include “neurodecolonization” (drawing possibilities from the idea of neuroplasticity), and “culture-based healing” (p. 10).

The authors trace all of these concepts to traditional Indigenous teachings – again demonstrating the significance of true decolonization in helping to find the way forward.

Walls, M.; Hautala, D.; & Hurley, J. (2014). ‘Rebuilding our community’: Hearing silenced voices on Aboriginal youth suicide. Transcultural Psychiatry, 51(1). 47-71.

The authors present a “multilevel approach to historical trauma” (p. 49) – explicitly naming colonization – as their starting place. This particular study builds on a longitudinal survey that was conducted throughout the US and Canada. This study consists of focus groups that took place at three separate First Nations reserve locations across central Canada. “Advisory members from each reserve agreed to recruit participants for two separate focus group sessions at each community: the first groups included Elders, and the second was comprised of service providers” (p. 51). As it turned out, all of the service providers were Aboriginal community members themselves.

Despite the fact that the theories informing the multi-level analysis included consideration of individual, family, and community (and more), participants did not identify individual risk factors (such as mental illness or depression). There were, however, “examples of interpersonal risk factors within the data” (p. 53), including such things as suicide clusters, and communication barriers (to name two). In terms of community-level factors, two themes that emerged from the data were “(a) insufficient services and coordination, and (b) lack of community accountability” (p. 58). Throughout the entire discussion macro-level factors were also discussed.

The authors make clear that despite the fact that these ‘levels’ of analysis may make it appear as if these factors are independent, the “overarching, unifying theme” among all of them and throughout their focus group discussions is “historical trauma” (p. 60). “Historical trauma was identified by participants as a fundamental cause of contemporary social problems. Three subthemes were identified: (a) effects of European contact and residential schools, (b) loss of identity, and (c) returning to a traditional way of life” (p. 61).

Yellow Horse Brave Heart, M.; Chase, J.; Altschul, D. (2011). Historical trauma among Indigenous peoples of the Americas: Concepts, research, and clinical considerations. Journal of Psychoactive Drugs, 43(4), 282-290.

To begin, the authors state that “a long-term goal of historical trauma intervention practice is to reduce emotional suffering among Indigenous Peoples of the Americas by developing culturally responsive interventions driven by the community to improve behavioral health” (p. 282). They describe the concept of historical trauma – defined as “as cumulative emotional and psychological wounding across generations, including the life span, which emanates from massive group trauma” (p. 283) – and its relevance to health disparities for Indigenous people as due to colonization.

They then outline responses to historical trauma, which are diverse and may depend on such things as the degree of abuse and violence that was experienced, the number of people from a particular community directly impacted (by residential schools, for instance), the degree and number of personal losses, and other factors. More research is needed on historical trauma responses (HTR), including how effective current interventions are at addressing it.

In terms of clinical implications, the authors begin by observing that most grief and bereavement research does not take into account such profound and collective historical losses. Indigenous experiences and approaches to loss must be meaningfully drawn on. Similarly, depression and PTSD interventions must also respond accordingly. In an effort to move in this direction, the authors draw on scales developed by others, including the Historical Loss Scale and Historical Loss and Associated Symptoms Scale that contribute to the body of empirical evidence about historical trauma. They also describe the Indigenous Peoples of the Americas Survey, which was in development at the time of writing, and being “designed to inform clinical practice and research on the effectiveness of interventions incorporating historical trauma and unresolved grief” (p. 285). It is hoped to increase access to knowledge, including Indigenous approaches to healing across communities. As an example, they share one short term, culturally grounded intervention with a particular focus on these experiences.

They do share a number of practice concerns. These include: 1) striking a balance between addressing collective shared experiences (i.e. historical trauma due to colonization) and preserving the diversity among Indigenous peoples and communities, 2) addressing ongoing systemic oppression and colonizing practices, and 3) addressing family level challenges that have resulted from residential school experiences. They conclude by advocating further research, as well as “continued development and evaluation of healing intervention models, grounded in Indigenous worldviews” (p. 288).

Wexler, L. (2014). Looking across three generations of Alaska Natives to explore how culture fosters Indigenous resilience. Transcultural Psychiatry, 51(1), 73-92.

This article takes as its starting place the growing body of research that connects culture with positive health outcomes, resilience, and well-being for Indigenous people. It aims to contribute a more nuanced understanding of this relationship to the body of knowledge by looking at similarities and differences of understandings of culture and its role among three generations of Inupiaq people. By exploring the different ways youth, adults, and elders “deploy cultural resources when overcoming challenges” much can be learned that might contribute to resilience and well-being.

All three groups discussed cultural oppression, and seeing culture as a source of strength. Elders also talked about overtly racist policies and how they impacted them directly. Many of them coped by finding a way to balance Inupiaq and Western ways. Adults identified the intergenerational impacts of historical trauma; many of them over time came to see themselves as activists, fighting back against the colonial system. They demonstrated a fierce commitment to reclaiming what had been stolen, while acknowledging the negative impacts of the injustices they have suffered.

Youth, on the other hand, spoke primarily of suicide. While they did link this with other struggles, and had a sense of some of the things their parents had gone through, they were more likely to connect suicide with lack of employment and addiction than with colonial policies and cultural oppression. Some of them expressed interest in cultural activities and practices, but often found that they competed with other interests and commitments (such as school, which started in prime hunting season) that had to be prioritized. “Youth did not note how this schedule prioritized western interests over indigenous ones” (p. 84). Despite this, many of them did gain strength from their culture, but many had difficulty naming how.

Significantly, while the three cohorts experienced many similar challenges, the youth “did not articulate them in the context of historical trauma, cultural strength, or even shared experience. Instead of drawing upon visions of a shared past and future rooted in Inupiaq values and traditions, Youth linked today’s issues to personal problems and family difficulties” (p. 87). Without this perspective, they were less able to access cultural resources for strength when facing challenges. This points to a collective responsibility to support movement in this direction.

Wexler, L. (2009). Identifying colonial discourses in Inupiat young people’s narratives as a way to understand the no future of Inupiat youth suicide. American Indian and Alaska Native Mental Health research: The Journal of the National Center. University of Colorado: Health Sciences Centre.

The author points out that 1) youth suicide rates in Indigenous communities are disproportionately high, and 2) some research connects this with historical community disruption and change, but 3) very few researchers explore the link to ongoing colonizing discourses and practices explicitly. After offering a brief summary of the history, demographics, and geography of the area in which her study takes place, the author outlines her Participatory Action Research process.

Her findings illustrate the difficulty in negotiating Western values Inupiat youth are taught through school (prioritizing individual choice) and traditional values from within their communities (prioritizing relational decision-making). The idea of individual choice leads to judgement of those (including themselves) when ‘bad’ decisions are made, because it doesn’t account for how relational processes inform action. “Caught within this web of relations, many people feel as if they have very little room to maneuver, even though they believe they should have control over their lives” (p. 13), further strengthening and internalizing colonial discourses by blaming people for not doing better.

On top of this, the youth expressed even bleaker prospects when they look forward – based on what they see, they expect adulthood to be even more stressful and difficult than youth. There is also an awareness among the young people that stress can take a particularly hard toll on men, who don’t share their emotional experiences as much. These perspectives were shared in response to the question “Why do you think people attempt or commit suicide” (p. 15). “In this frame, one could understand the alarmingly high Inupiat youth suicide rate as the result of healthy pathways thwarted by cultural discontinuities and active oppression” (p. 16).