Five Critical “Cs” for Mental Health Services: A Focus on Aboriginal People in Canada

1. Five Critical “Cs” for Mental Health Services: A Focus on Aboriginal People in Canada Addressing Mental Health: The Missing Link to Effective HIV Prevention, Care, Treatment and Support Randy Jackson School of Social Work and the Department of Health, Aging and Society McMaster University XIX International AIDS Conference Washington, DC July 24, 2012

2. Positioning Myself . . . “‘There is always a story that frames the nature of research.’ Hence, my research inclination or my way of knowing is directly/indirectly related to my position in the story.” (Dunbar, 2008, p. 89)

3. HIV/AIDS in Aboriginal Canada • Aboriginal peoples are over-represented • Aboriginal peoples are “3.8% of the Canadian population … and yet an estimated 4,300 to 6,100 Aboriginal were living with HIV (including AIDS) in Canada in 2008 (i.e., 8.0% of all prevalent HIV infections)” (PHAC, 2010, p. 2). (PHAC, 2010)

4. HIV/AIDS in Aboriginal Canada • Aboriginal people are more likely to have a later diagnosis compared to non-Aboriginal people (Stokes, Pennock, & Archibald, 2006) • Slower uptake of anti-retroviral treatments (Wood et al, 2006) • Less access to experienced physicians (Miller et al, 2006) • Higher morbidity • Shorter survival times • A mortality rate three times higher than for non-aboriginals (Lima, 2006)

5. Aboriginal Peoples and Mental Health in Canada • Psychological distress (Aboriginal vs. non-aboriginal) • Greater frequency of depression (4 to 5 times higher) (Kirmayer et al 2000; Manson et al 1985) • Higher rates of suicide (3 to 5 times higher) (Health Canada, 1998; Kirmayer et al 1992) • Higher rates of drug/alcohol use (Hirschfeld et al 1990; Gray et al 2001; Jacobs & Gill, 2001) • Subjective experiences differ (i.e., appear similar but not identical) (O’Nell, 1996; Cain, 2011; Cain, 2012) • Ways to reach out and help are comprised (Cain, 2011; Cain, 2012) • Under represented in HIV/AIDS mental health research in Canada • Under represented in the development of interventions • Care can be poorly designed to meet cultural needs

6. Canadian Aboriginal AIDS Network CAAN Mandate and Mission • The Canadian Aboriginal AIDS Network (CAAN) is a not-for-profit coalition of individuals and organizations that provides leadership, support and advocacy for Aboriginal people living with and affected by HIV/AIDS, regardless of where they reside. Spirit and Vision Of CAAN • CAAN is a national Aboriginal organization and as such is committed to addressing the issues of HIV within a Native context. Although the beliefs of Aboriginal people vary widely from region to region and from person to person, the agency has made a commitment to conduct its activities in a spirit of Native wholeness and healing. This disease can only be overcome by respecting our differences and accentuating our unity of spirit and strength.

7. CAAN’s Research and Policy Unit • Reflection and five key teachings (i.e., themes) • Canadian Aboriginal People Living with HIV/AIDS: Care, Treatment and Support Issues (2002-2005) • Depression among Aboriginal People Living with HIV/AIDS (2005-2008) • Culturally Competent Care for Aboriginal People Living with HIV/AIDS in Canada (2005-2008) • Meta-Ethnography of HIV Prevention Services for Women in Canada (2008-2011) • Participatory Action Research, and Indigenous and Decolonizing Methodologies (2008-2012)

8. Context • Social determinants of health (e.g., poverty, unstable housing) are important, particularly the negative effects of ongoing colonialism (e.g., residential school, fostering/adoption, cultural disruption) • Cultural background and circumstances influence experiences of depression • Another challenge in a long series of challenges, one not necessarily the most important • Compounded by stigma, racism, increased isolation, alienation and feelings of culpability • Rather than solely psychological oriented – on the inner self – depression and HIV often experience in relational or social terms • For some – familiar ways – drug/alcohol use, little faith and avoidance of health services • For others –Testing positive and experiences of depression often viewed as a turning point to leading a “good journey” (Cain, 2012; Cain, 2011; Jackson, 2008)

9. Culture • Community cultural beliefs about health and healing matter • Diversity (language, cultures, traditions, beliefs and values) • Layered against age and gender • Lack of specificity can lead to generic or pan-Aboriginal approaches • A single focus on “contexts of risk” (e.g., IDU, street involvement, etc.) may also lead to needs of other Aboriginal peoples who fall outside these categories being ignored (Peltier, 2012) • We need to more aggressively attend to notions of culture in both research and in service design and provision (Jackson and Reimer, 2005)

10. Connection • Experiences of depression, alcohol/drug use, use of health services often expressed in terms of connection/disconnection • Connection fostered when services are welcoming, comfortable, relaxed and safe – often describing providers as “second families” • Personable relationships were critical in “relational care” – meaningful interactions, supporting the whole person, etc.

11. Care • Allied and alternative Western health care providers have long advocated for models of complementary and holistic care (LaValley & Verhoef, 1995; Darlington, 2011) • Strength-based, focuses on resiliency, and is community wide • Localized, culturally defined, age appropriate, gender specific, relational ethic (i.e., tradition, customs, and local conditions) • Despite this, community consultations highlight a persistent concern – little or no involvement in the design or delivery of care services (Peltier, 2012)

12. Creativity • Additional research needed coupled with methodological innovation (i.e., participatory, decolonizing and indigenous methodologies) • Traditional research approaches have been criticized as colonial (Smith, 1999; Wilson, 2007) • Need to more explicitly connect with what and how Aboriginal peoples come to know the world, including culturally-based understanding of health and wellbeing (Wilson, 2007) • Theories that support and sustain Aboriginal cultures and worldviews (Wilson, 2007)

13. Discussion • These critical features - responding to mental health and HIV - are important; but why do we experience difficulty addressing them? • Time and money • The challenge of complexity • Worldview

14. For Further Information ... • Research reports are available for download from the Canadian Aboriginal AIDS Network at http://www.caan.ca • For more information about CAAN and their programs, please contact Ken Clement at kenc@caan.ca or Renee Masching at reneem@caan.ca • For more information about this presentation, please contact Randy Jackson at jacksr3@mcmaster.ca

15. Key References Cain, R., Jackson, R., Prentice, T., Mill, J., Collins, E., Barlow, K. (2011). Depression Among Aboriginal People Living with HIV in Canada. Canadian Association of Community Mental Health, 30 (1), 105-120. Cain, R., Jackson, R., Prentice, T. Collins, E., Mill, J., Barlow, K. (2012). Experience of HIV Diagnosis Among Aboriginal People Living with HIV/AIDS and Depression. Qualitative Health Research (in review). Barlow, K., Loppie, C., Akan, M., Jackson, R., MacLean, L., Reimer, G., Hall, L. (2008). Relational Care: A Guide to Health Care and Support for Aboriginal People Living with HIV/AIDS. Ottawa, Ontario: Canadian Aboriginal AIDS Network. Barlow, K., Loppie, C., Jackson, R., Akan, M., MacLean, L., Reimer, G. (2008). Culturally Competent Service Provision Issues Experienced by Aboriginal People Living with HIV/AIDS. Pimatisiwin, 6 (2), 155-180. Jackson, R., Cain, R., Prentice, T., Collins, E., Mill, J., Barlow, K. (2008). Depression Among Aboriginal People Living with HIV/AIDS. Ottawa, Ontario: Canadian Aboriginal AIDS Network. Jackson, R. & Reimer, G. (2005). Canadian Aboriginal People Living with HIV/AIDS: Care, Treatment and Support Issues. Ottawa, Ontario: Canadian Aboriginal AIDS Network. Peltier, D., Jackson, R., Prentice, T., Masching, R., Monette, L., Fong, M., Shore, K. (2012). When Women Pick Up Their Bundles: HIV Prevention and Related Service Needs of Aboriginal Women in Canada. In Gahagan, J. (Ed.), HIV Prevention and Women in Canada. Toronto, Ontario: Canadian Scholars’ Press. (In Review).