UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The nature of the tensions and disjunctures between aboriginal understandings of and responses to mental… Smye, Victoria L. 2004

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_2004-902706.pdf [ 15.28MB ]
Metadata
JSON: 831-1.0091790.json
JSON-LD: 831-1.0091790-ld.json
RDF/XML (Pretty): 831-1.0091790-rdf.xml
RDF/JSON: 831-1.0091790-rdf.json
Turtle: 831-1.0091790-turtle.txt
N-Triples: 831-1.0091790-rdf-ntriples.txt
Original Record: 831-1.0091790-source.json
Full Text
831-1.0091790-fulltext.txt
Citation
831-1.0091790.ris

Full Text

T H E N A T U R E OF T H E TENSIONS A N D DISJUNCTURES B E T W E E N A B O R I G I N A L U N D E R S T A N D I N G S O F A N D RESPONSES T O M E N T A L H E A L T H A N D I L L N E S S A N D T H E C U R R E N T M E N T A L H E A L T H S Y S T E M B y V i c t o r i a L . S m y e B . A . B r o c k Unive r s i ty 1986 M . H . S c . M c M a s t e r Un ive r s i t y 1988 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F D O C T O R O F P H I L O S O P H Y I N N U R S I N G i n T H E F A C U L T Y O F G R A D U A T E S T U D I E S Schoo l o f N u r s i n g ^ W e ac^epphip thesis as conforming to the required standard T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A February 18, 2004 © V i c t o r i a Smye 2004 11 A B S T R A C T The Nature of the Tensions and Disjunctures Between Aboriginal Understandings of and Responses to Mental Health and Illness and the Current Mental Health System A b o r i g i n a l peoples continue to be affected by the mental heal th po l ic ies , structures, and soc ia l organiza t ion o f the dominant culture w h i c h tends to exclude them. T h i s study explored the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental heal th and i l lness and the current mental health system. U s i n g an ethnographic design in fo rmed by pos tcolonia l and cr i t ica l perspectives, in-depth ind iv idua l interviews were conducted w i t h A b o r i g i n a l people w o r k i n g i n menta l health and related fields; p o l i c y makers , bo th A b o r i g i n a l and n o n - A b o r i g i n a l ; and nurses. A focus group in terv iew was also conducted w i t h health care providers (N=31). T h e 1998 M e n t a l Hea l th P l a n and several documents o f reform were also cr i t iqued. Incorporat ing aspects o f pos tco lonia l theories, this study illustrates h o w dominant culture ideologies , mental health inst i tut ional po l ic ies , and everyday practices intersect to shape the tensions and disjunctures. U s i n g the in te rv iew data and p o l i c y crit iques, I describe h o w mental health institutions and po l ic ies support the embeddedness o f an ass imi la t ion ethos - revealed as paternalistic care, ethnocentr ism, and the not ion o f [ imjpart ial p o l i c y dec is ion-making . A b o r i g i n a l perspectives are largely excluded vis a v i s the intersection o f the dominance o f the b iomed ica l m o d e l (i.e., psychiatry) and the ongoing ju r i sd ic t iona l debate regarding who is responsible for A b o r i g i n a l mental health. D o m i n a n t cul tural f rameworks and a lack o f clar i ty about who provides what are in terwoven and reproduced i n the everyday w o r l d o f mental health service de l ivery , be ing marked by acts o f omis s ion , c o l o n i a l ambivalence , and the Ill normal iza t ion o f A b o r i g i n a l suffering. Nevertheless, where normal i za t ion occurs , there are powerful points o f A b o r i g i n a l co l lec t ive resistance and heal ing. The study concludes by arguing for the development o f c r i t i ca l consciousness to challenge sustaining ideologies , inst i tut ional discourses, and predominat ing practices that exclude A b o r i g i n a l i t y . The concept o f cul tural safety, pos i t ioned w i t h i n pos tco lonia l perspectives, is d iscussed as a means o f fostering cr i t ica l consciousness. B y e x a m i n i n g his tor ica l ly mediated relations o f power , longstanding patterns o f paternal ism, ethnocentrism and assumptions about A b o r i g i n a l i t y from a cultural safety lens, there is the potential to shift knowledge and attitudes i n nurs ing and more broadly, i n health care. L o c a t i n g A b o r i g i n a l mental health and mental health care w i t h i n its wider h is tor ica l , soc ia l , po l i t i c a l and economic context can help nurses to more ful ly contribute to soc ia l jus t ice i n the area o f A b o r i g i n a l mental health. T A B L E OF C O N T E N T S A B S T R A C T n T A B L E O F C O N T E N T S ™ L I S T O F T A B L E S v ! ! . A C K N O W L E D G E M E N T S v n ' C H A P T E R O N E - I N T R O D U C T I O N 1 B a c k g r o u n d to the P r o b l e m 1 The Cent ra l P r o b l e m 7 Research Object ives 8 Organiza t ion o f the Disser ta t ion 9 C H A P T E R T W O - T E N S I O N S A N D D I S J U N C T U R E S W I T H I N A N H I S T O R I C A L C O N T E X T 12 Contemporary Determinants o f A b o r i g i n a l M e n t a l Hea l th 13 E p i d e m i o l o g i c a l Construct ions o f M e n t a l Hea l th and Illness 17 L o c a t i n g Tens ions and Disjunctures: A s s i m i l a t i o n 25 Hi s to r i ca l Contex t o f Paternal ism i n Indian Hea l th P o l i c y 30 Current Context : Se l f -Government and H e a l i n g 41 M e n t a l Hea l th R e f o r m : Current Patterns o f Tens ions and Dis junctures 45 C o n c l u d i n g C o m m e n t s 52 C H A P T E R T H R E E - L O C A T I N G T H E P R O B L E M I N A N H I S T O R I C A L C O N T E X T : T H E P O S T C O L O N I A L 55 Pos tco lon ia l i sm and A b o r i g i n a l V o i c e 56 T h e Pos tco lon ia l : Theore t ica l Foundat ions 60 Subaltern V o i c e s : Pos i t ion ing M a r g i n a l i z e d V o i c e s and K n o w l e d g e 65 T h e o r i z i n g about Rac i a l i z a t i on , Cul ture , Difference and Other 67 Race and R a c i a l i z a t i o n 67 Intersections o f Rac i a l i z a t i on , C lass , Race , Gender and H e a l t h 69 The V a r i o u s R a c i s m s 71 Cul ture and C u l t u r a l i s m 75 Cu l tu ra l Safety 80 The Importabi l i ty o f Cu l tu ra l Safety to the Canad ian Con tex t 82 Cu l tu ra l Safety as a M o r a l Discourse Informing P o l i c y Cr i t ique 83 C o n c l u d i n g C o m m e n t s 85 Summary 86 S u m m a r y o f the State o f K n o w l e d g e 87 C H A P T E R F O U R - R E S E A R C H D E S I G N A N D I M P L E M E N T A T I O N 89 Introduction 89 Select ing a D e s i g n : C r i t i c a l Ethnography 90 F r o m T h e o r y to a M e t h o d o f Inquiry: A Pos tco lon ia l F r a m e w o r k 92 The Research D e s i g n 95 The Research Sett ing 96 B e g i n n i n g i n the F i e l d : B u i l d i n g A l l i a n c e s 96 S a m p l i n g Procedures 98 Recrui tment 101 O v e r v i e w o f Part icipants 102 A b o r i g i n a l Part icipants W o r k i n g i n M e n t a l H e a l t h and Re la ted F i e ld s 102 P o l i c y Participants 103 Focus G r o u p Part icipants 104 Nur se Participants 104 Data C o l l e c t i o n M e t h o d s and Procedures 106 R e c o r d i n g Fieldnotes 106 Research as Conversa t ion : T h e Ethnographic Interviews 107 Interviews w i t h A b o r i g i n a l Participants i n M e n t a l H e a l t h and Rela ted F ie lds 107 In-depth Interviews w i t h P o l i c y Participants 109 In-depth Interviews w i t h Nurses 110 Focus G r o u p Interview 110 P o l i c y R e v i e w / C r i t i q u e I l l Da ta A n a l y s i s 113 Pos tco lon ia l [Cr i t ica l ] Discourse A n a l y s i s 116 Ensur ing Scient i f ic Q u a l i t y 118 Expec ted Outcomes: Research as Praxis 121 E th i ca l Considerat ions 122 L imi ta t ions o f the Study 123 Ref l ex ive Considerat ions: The L o c a t i o n o f the Researcher 123 C o n c l u d i n g Comment s 128 C H A P T E R F I V E - I D E O L O G I E S A N D S T R U C T U R E S : T H E S C A F F O L D I N G 130 D r a w i n g o n Theories o f Ideology 131 P romot ing the Wel fa re o f the C o l o n i z e d : Paternalist ic Care 136 Ethnocentr ism: Render ing Invis ib le the Other 150 Intersections: The Ideology o f [ Impar t i a l i ty , [Institutional] R a c i s m , and Class 162 Summary 174 C H A P T E R S E X - M E D I A T I N G P R A C T I C E S : M E N T A L H E A L T H I N S T I T U T I O N S A N D P O L I C I E S 175 Bureaucrat ic Obfusca t ion and Abroga t ion : W h o s e Respons ib i l i ty is A b o r i g i n a l M e n t a l Heal th? 178 Reg iona l i za t ion 189 W o r l d v i e w s : D r a w i n g o n Discourses o f Cul tu re 195 Summary 210 C H A P T E R S E V E N - E V E R Y D A Y P R A C T I C E S I N M E N T A L H E A L T H : T H E T E N S E T H I N G S T H A T H A P P E N 212 Introduction 212 Everyday L i f e 215 v i A c t s o f O m i s s i o n ^10 C o l o n i a l A m b i v a l e n c e : H y p e r v i s i b i l i t y and H y p e r i n v i s i b i l i t y 228 N o r m a l i z a t i o n and Resistance 242 Summary 249 C H A P T E R E I G H T - N A T U R E O F T H E T E N S I O N S A N D D I S J U N C T U R E S 251 O v e r v i e w o f the E m p i r i c a l F ind ings 253 Ideologies and Structures: T h e Scaf fo ld ing 253 M e d i a t i n g Practices: M e n t a l Hea l th Institutions and Po l i c i e s 257 Everyday Pract ices i n M e n t a l Hea l th : T h e Tense Th ings That H a p p e n 259 Implicat ions: D e v e l o p i n g a C r i t i c a l Consciousness i n N u r s i n g 262 Foster ing C r i t i c a l P o l i t i c a l and S o c i a l Consciousness i n N u r s i n g : 267 Cu l tu ra l Safety as a M o r a l Discourse 269 O v e r a l l Recommenda t ions A r i s i n g f rom the Study 273 C l i n i c a l 273 Educa t ion 274 Research 275 P o l i c y 276 C o n c l u d i n g C o m m e n t s 277 R E F E R E N C E S 278 A p p e n d i x A : Informational Pamphlets for Participants 304 A p p e n d i x B : Consent F o r m s for Part icipants 309 A p p e n d i x C : Interview G u i d e s 314 A p p e n d i x D : Desc r ip t i on o f Federa l and P r o v i n c i a l M e n t a l Hea l th Services 317 Vll L I S T O F T A B L E S Table 1: S o c i o - D e m o g r a p h i c Characterist ics o f Study Part icipants Page 105 Vlll A C K N O W L E D G E M E N T S First, I am indebted to the participants in this study, from whom I learned so much. Everyone was extremely generous with their time and energy despite their heavy schedules and commitments; without their involvement, this study would not have been possible. Secondly, I would l ike to acknowledge the generous support for this study that was provided by the Canadian Institutes o f Health Research through a P h D fellowship. Thanks also to Sue Humphreys who transcribed the research materials. Thirdly , it has been a real privilege to work with the six outstanding scholars who comprised m y dissertation committee: Drs. Joan Anderson, M i k e Burgess, Joy Johnson, R o d M c C o r m i c k , John O ' N e i l , and Sally Thorne. I am tremendously grateful for their intellectual generosity and support. I am especially grateful to Joan Anderson who provided me with the finest o f supervision and fanned m y interest in social justice in the area o f culture and health. John O ' N e i P s work has been instrumental in shaping m y own and I greatly appreciate the expertise he brought to this study. M a n y thanks to Joy Johnson and to Sally Thorne who have always challenged m y thinking and provided ongoing support during m y dissertation work. M y thanks go also to R o d M c C o r m i c k who was a wonderful resource in the area o f Abor ig ina l mental health and to M i k e Burgess who prompted my thinking in the area o f moral decision-making. Furthermore, I am incredibly thankful to my mentors, colleagues, and friends B i l l Musse l l , Larry Jorgenson, and Nadine Caplette for their unfailing generosity o f knowledge, support, and wisdom. A huge thank you goes to m y colleagues and dear friends Annette Browne and L o r i d 'Agincourt - to Annette with whom I share a commitment to this work and to Lor i whose analytic abilities continue to encourage me - to both o f them, thanks for being there through thick and thin. M y husband Gary Kinney has supported me in many ways: by talking with me about my ideas, becoming m y technical support, and providing me with encouragement when I needed it most. Thank you for sticking with me in this incredibly long journey! I also thank my many other friends and family who supported me in numerous ways during this time. Lastly, and importantly, I thank my children D a v i d and Regina (my daughter-in-law), E r in and M i c h a e l (my son-in-law) and Jared for being there every step o f the way - you inspire me. For Madeline, my granddaughter, I am simply thankful. In addition, I thank my step-children Michae l and Catherine for being so supportive. 1 Firs t I w o u l d l i k e to locate this work . I speak as a n o n - A b o r i g i n a l w o m a n and therefore do not speak from a Fi rs t Na t ions , M e t i s , or Inuit perspective but rather from a point o f inquiry . I also b r ing to this w o r k m y understandings from c l i n i ca l w o r k , research, and teaching i n the area o f mental health over the past 30 years and from m y more recent f i e ldwork w i t h A b o r i g i n a l peoples . 1 C H A P T E R O N E E v e r y disease has two causes. The first is pa thophys io logica l ; the second, po l i t i ca l . ( R a m o n Ca ja l , pathologist , 1899, ci ted i n Brant , 1993, p. 55) T H E I N T R O D U C T I O N B a c k g r o u n d to the P r o b l e m A b o r i g i n a l peoples i n B r i t i s h C o l u m b i a ( B C ) and other areas o f Canada continue to experience mental health inequali t ies and barriers to accessing mental heal th care that ul t imately affect i n d i v i d u a l , f ami ly , and communi ty mental health. A signif icant issue affecting equitable access and use o f mental health services arises from what I have ca l led , the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness , and the current mental health system. 1 Today, seventeen percent of Canada's Aboriginal people live in BC. This represents a large and culturally diverse community consisting of over 94,000 status Indians1 as well as 70,000 non-status Indians and Metis. There are almost 200 bands (the bureaucratic organizational structure) with membership ranging from less than 10 to over 1700. Most of these bands have organized into 33 Tribal Councils (Elliott and Foster, 1995, pp. 98-100). In this dissertation, in much the same way as Browne (2003), I use these designations as consistent with the terminology used by the Royal Commission on Aboriginal Peoples (1996a). The term Aboriginal peoples refers generally to the Indigenous inhabitants of Canada, including First Nations, Metis and Inuit peoples without regard to their separate origins and identities. The Commission stresses that the term Aboriginal people "refers to organic political and cultural entities that stem historically form the original peoples of North America, rather than collections of individuals united by so called 'racial' characteristics. The term includes the Indian, Inuit and Metis peoples of Canada (see section 35(2) of the Constitution Act, 1982)" (p. xii). Specifically, the term "First Nation" replaces the term "Indian" and "Inuit" replaces the term "Eskimo". The terms Indian and Eskimo, however, continue to be used in federal legislation and policy, for example, the Indian Act, and in government reports and statistical data, particularly those generated by the federal department of Indian and Northern Affairs Canada (INAC). INAC retains the terms "status" or "registered Indian" to refer to people who have been registered by INAC as members of a First Nations under the terms of the Indian Act. When distinctions between Aboriginal groups are needed, specific nomenclature is used (Browne). 2 E a r l y i n the co lon i za t i on process an assimilat ionist ethos preva i led i n w h i c h A b o r i g i n a l peoples as "wards o f the state" were to be ass imilated into the fabric o f Canad ian society. D o m i n a n t culture ideologies , mental health inst i tut ional po l i c i e s , and everyday practices have intersected to shape the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. A b o r i g i n a l be l i e f systems regarding health, heal ing and i l lness have been largely ignored, often be ing rendered inv i s ib l e . C o l o n i a l i s m is a dynamic phenomenon w h i c h intersects w i t h and is inf luenced by socia l , economic , po l i t i ca l , and his tor ical processes; "yesterday's c o l o n i a l i s m has certain features i n c o m m o n w i t h today 's co lon ia l i sm, but today's c o l o n i a l i s m has its o w n impr ima tu r" 2 ( M c C o n a g h y , 1997, p. 77). Howeve r , whether speaking o f the past or present, c o l o n i a l i s m manages to disrupt i n a spectacular fashion the cul tural l i fe o f co lon i zed people through the expropr ia t ion o f l and (geographical incursion) and rights (Fanon , 1967; Frideres, 1998), the negat ion o f sociocul tura l [psychological] identities (Fanon , 1967; Frideres, 1998), the domina t ion o f legal relations introduced by the occupy ing power (Fanon , 1967), the marg ina l i za t ion 3 o f A b o r i g i n a l peoples and their customs through the interconnected "processes o f external po l i t i ca l control and A b o r i g i n a l e conomic dependence" (Frideres, 1998, pp. 3-4), and, the domina t ion o f ideologies based o n race and s k i n co lou r w h i c h place the co lon ize r as superior to the co lon ized (Frideres, 1998, p . 7). M o r e ins id ious ly , c o l o n i a l i s m is attached to a po l i t i c a l economy that renders i t inherently incapable o f meet ing 2 McConaghy (1997) speaks about colonialism in the context of Australia and the indigenous people there. Instead of speaking about health and social policy, she refers to educational and social policy; however, I believe that what she says about these policies is equally applicable to health. 3 A process by which mainstream society is represented as being at the center of community, while those with less power and resource are relegated to the periphery. Allocation to the periphery is usually based on identities, associations, experiences, and environments (Hall, Stevens, & Meleis, 1994; Reimer Kirkham, 2000). 3 the economic , [health] and soc ia l needs o f the co lon i zed people (Fanon , 1967) . 4 A c c o r d i n g to Frideres (1998) the p rov i s ion o f low-qua l i ty socia l services is a characteristic o f co loniza t ion . H e says: [t]he ul t imate consequence o f co lon iza t ion is to w e a k e n the resistance o f the c o l o n i z e d A b o r i g i n a l s to the point at w h i c h they can be control led . Whether the mot ives for co lon iza t ion are rel igious, economic , or p o l i t i c a l , the rewards are c lear ly economic , (p. 7) C o l o n i a l i s t domina t ion has had extremely deleterious effects o n A b o r i g i n a l peoples i n B C and across Canada and many l i ve i n condit ions descr ibed as T h i r d W o r l d i n both urban and reserve settings 5 ( B C , 1998, p. 27 ; Fleras & El l io t t , 1992, p . 16). A b o r i g i n a l people are more l i k e l y [than non-Abor ig ina l s ] to face inadequate nutr i t ion, substandard hous ing and sanitation, unemployment and poverty, d i sc r imina t ion and rac i sm, v io lence , inappropriate or absent services, and subsequent h igh rates o f phys ica l , socia l and emot iona l i l lness , injury, d isabi l i ty and premature death. ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1996a, p. 107) Today , as central players i n the tragedy o f co lon iza t ion , A b o r i g i n a l peoples have been profoundly affected by the mental health pol ic ies , structures, and soc ia l organiza t ion o f the dominant culture w h i c h tends to exclude them. The 1998 M e n t a l Hea l th P l a n , Revitalizing and Rebalancing British Columbia's Mental Health System ( R R B C ) , sets out the objectives and strategies for the most recent mental health reform designed to promote the opt imal mental health and par t ic ipat ion o f people w i t h mental i l lness i n B r i t i s h C o l u m b i a ' s 4 Fanon (1967) notes that colonialism blinds the colonizer to the consequent negative effects of colonization (in terms of the social consequences for the colonized people). 5 Often referred to as the Fourth World (O'Neil, 1986). 4 communi t ies ( R R B C , 1998, p.5). T h i s p l an is the product o f a r e v i e w o f menta l health care systems and the broader project o f health reform over the past decade, as w e l l as an extensive consultative process across the p rov ince o f B r i t i s h C o l u m b i a attempting to address the current challenges that compromise qual i ty care for people w i t h menta l i l lness , that is , those who experience long-term mental i l lness and disabi l i ty , and those w h o experience acute, episodic, serious and persistent menta l d isorder . 6 T h e overa l l tenor o f the p l an is reflective o f Western understandings o f health and il lness and continues to be strongly inf luenced by psychiatry, w i t h its attachment to b iomed ica l tradit ions, i nd iv idua l i s t i c approaches to treatment, and its long-s tanding history o f cul tural bl indness (Fernando, 1991; G o o d , 1996) and r a c i s m 7 (Fernando, 1991). A l t h o u g h most recently there has been gradual shift to family-focused and communi ty-based care, the mental health system remains a l igned w i t h an i l lness service m o d e l . E v e n where il lness service models used across Canada reflect a more hol i s t ic , mul t id i sc ip l ina ry , and mu l t i -sectoral approach to health, general ly this development w i t h i n Wes te rn society does not fu l ly reflect the hol is t ic approaches o f A b o r i g i n a l traditions ( O ' N e i l & Pos t l , 1994; O ' N e i l , L e m c h u k - F a v e l , A l l a r d , & Pos t l , 1999), nor does it recognize or acknowledge the soc iopol i t i ca l and h is tor ica l context o f A b o r i g i n a l mental health. 6 Serious and persistent mental illness usually refers to the following categories of illness as found in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, test revision) (DSM-IV-TR) (American Psychiatric Association (APA), 2000), for example, schizophrenia and other psychotic disorders; mood disorders, including bipolar disorder; and anxiety disorder. The 1998 Mental Health Plan (RRBC) commits to providing mental health treatment to "those who experience serous long-term mental illness and disability" and "to those who experience acute, episodic serious mental illness." This includes persons " who do not voluntarily access care, as well as those who present with additional conditions (e.g., substance misuse, developmental disabilities, positive HIV status)" (p. 18). 71 use racism in the same sense that Fernando (1991) does as essentially about '"institutionally generated inequality' based on concepts of racial difference; although it affects the behaviour of individuals, 'prejudiced people are not the only racists'" (p. 24). As Fernando notes, acknowledgment of difference based on notions of race tends to inscribe patterns of inclusion and exclusion based on colour and/or phenotypic characteristics. A l t h o u g h many A b o r i g i n a l people have constructed a coherent and complex medica l system out o f disparate b iomed ica l and A b o r i g i n a l med ica l systems, general ly speaking, program de l ive ry mode l s w h i c h reflect predominately Western European concepts o f mental health and i l lness have been ident i f ied as largely ineffective i n responding to the needs o f Fi rs t Na t ions people ( M c C o r m i c k , 1996, 1998; O ' N e i l , 1993a; W a r r y , 1998). There is a tendency b y A b o r i g i n a l peoples not to use the mental health services p rov ided by the dominant culture ( M c C o r m i c k , 1996; T r i m b l e & F l e m i n g , 1990). I f services are accessed, approximate ly one-ha l f o f these ind iv idua l s drop out (Sue, 1981; D u r a n & Duran , 1995), and for many, treatments are not effectual (Duran & Duran , 1995, 2000; M c C o r m i c k , 1996; Sue & Zane , 1987; T r i m b l e & F l e m i n g , 1990). M e n t a l health programs and services designed i n keeping w i t h dominant cul tura l (b iomedica l ) v i e w s o f mental health and i l lness ignore the unique cul tura l identi t ies, histories, and soc iopo l i t i ca l contexts o f the everyday l ives o f A b o r i g i n a l peoples, put t ing them at r i sk o f not hav ing their menta l heal th care needs recognized and met. Persistent soc ioeconomic inequities and cont inued marg ina l iza t ion have taken a to l l o n the mental heal th o f many A b o r i g i n a l people. A l t h o u g h they suffer f rom many o f the same mental health p rob lems as the general popula t ion, rates o f menta l heal th problems such as suic ide , depression, substance abuse and domest ic v io lence are s igni f icant ly higher i n many communi t i es ( N e l s o n & M c C o y , 1992) and the overa l l menta l health status o f A b o r i g i n a l peoples is marked ly worse than that o f n o n - A b o r i g i n a l people b y almost every measure ( B r i t i s h C o l u m b i a P r o v i n c i a l Hea l th Off icer ( B C P H O ) , 1996, 2002 ; Fi rs t Na t ions Inuit and Hea l th B r a n c h ( F N I H B ) , 2 0 0 1 ; Foster, M a c D o n a l d , T u k , U h , & Talbot , 1995; M a c M i l l a n , 1996; O ' N e i l et a l , 1999; V a n c o u v e r / R i c h m o n d H e a l t h B o a r d ( V R H B ) , 1999 8 ) . A l t h o u g h most statistics continue to be generated by ep idemio log ica l studies and thus Western measures o f health and i l lness , many A b o r i g i n a l people concur w i t h the v i e w that the issue o f A b o r i g i n a l mental health requires urgent attention ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1995, 1996b). Instead o f t h i n k i n g about mental health problems as m e d i c a l l y defined disorders, many A b o r i g i n a l caregivers and p o l i c y analysts bel ieve that i t is more appropriate to focus o n the mental health issues that pose the most serious threat to the su rv iva l and health o f A b o r i g i n a l communi t i es . T h e y argue that su ic ida l and other self-destructive behaviours such as a lcohol and drug abuse and v io lence are pr imar i ly " a by-product o f the c o l o n i a l past w i t h its layered assaults o n A b o r i g i n a l cultures and identit ies" ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1995, p. 21) , the k i n d o f assaults that have led to " a state o f pervasive demora l iza t ion related to the b reakdown o f the mora l order i n c l u d i n g re l ig ious , k insh ip and other soc ia l insti tutions such as the f ami ly un i t . . . " (Ki rmayer , 1994, p. 23). T h i s sense o f pervasive demora l i za t ion is what D u r k h e i m (19571987) cal ls "anomie . " Bran t (1993) describes this as [a]n environment o f despair o n many reserves - an environment that includes welfare dependency, unemployment and poor educational experiences, an environment o f poverty and powerlessness and anomie produces the t r iad o f a l coho l and other substance abuse, su ic idal ideation, suic ide attempts and depression, (p. 1) 8 The Vancouver/Richmond Health Board is now the Vancouver Coastal Health Authority as a consequence of a recent reorganization in the health sector that included a shift in regional boundaries. 7 T h i s does not mean that A b o r i g i n a l peoples do not l i ve w i t h schizophrenia , b ipolar disorder and other affective disorders, or that these are not o f concern to A b o r i g i n a l communi t ies , but rather that these disorders are considered less problemat ic i n relat ion to commun i ty su rv iva l . In fact, l i t t le i s k n o w n about the exact prevalence o f mental health disorders, as def ined i n the D S M - I V - T R ( A P A , 2000) , i n the Canad i an A b o r i g i n a l popula t ion (Brant, 1 9 9 4 ) . 9 H o w e v e r , there is agreement i n m u c h o f the literature that A b o r i g i n a l peoples appear to be at higher risk for mental health problems than most o f the general populat ion, l i k e l y attributable to the consequences o f co lon iza t ion (Armst rong , 1991; Brant , 1994; Darymple , 1995; D u r a n & Duran , 1995, 2000; F r i t z & D ' A r c y , 1989; J i l e k - A a l l , 1974; Kel tner , 1993; R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1996a, 1996b; Sampath, 1974). T o understand the meaning o f health w i t h i n a soc iopo l i t i ca l and cul tura l context, one needs to elucidate "the intersectionali ty and simultaneity o f race, gender, and class relations, the practice o f rac ia l iza t ion , the connectedness to h is tor ica l context, and h o w the curtailment o f l i fe opportunit ies created b y structural inequities influences heal th" (Ande r son & R e i m e r K i r k h a m , 1999, p. 63). T h e C e n t r a l P r o b l e m The 1998 M e n t a l Hea l th P l a n as it exists w i t h i n current mental health reform i n B C has tended to gloss over and/or ignore the broader soc iopo l i t i ca l and economic factors that shape the meaning and exper iencing o f mental health and i l lness for A b o r i g i n a l peoples. In l ight o f these exc lus ions and the inequitable mental health status o f A b o r i g i n a l peoples, the central problemat ic addressed i n this study is the nature o f the tensions and disjunctures 9 Of note, it is not known whether these disorders occur less often in Aboriginal people or whether the low access figures are simply a reflection of the fact that Aboriginal people have poorer access to diagnostic and treatment facilities for mental health problems - and/or are less likely to use them (Royal Commission on Aboriginal Peoples, 1995, p. 21). 8 between A b o r i g i n a l understandings o f and responses to mental heal th and i l lness and the current mental health system. It should be noted that I a m not e luc ida t ing A b o r i g i n a l understandings per se, but rather focusing attention o n the conf l ic t between those understandings and the current mental health system. In particular, I a m e x a m i n i n g and descr ibing the nature o f the tensions ' 0 or effects produced between these two forces w h i c h seemingly are often i n confl ic t . The separations created between parties are what I refer to i n this dissertation as the disjunctures. R e s e a r c h Ob jec t ives The overarching purpose o f the dissertation is to more fu l ly understand: (a) the nature o f the tensions and disjunctures ment ioned above, and (b) to examine the extent to w h i c h the tensions and disjunctures shape mental health care to A b o r i g i n a l peoples. T o address this problem, an ethnographic study informed by postcolonia l and c r i t i ca l perspectives was conducted. T h e specif ic objectives o f the research were to: 1. expl icate the nature/attributes o f the tensions and disjunctures, 2. identify the aspects o f these attributes that are most problemat ic for people, 3. identify the structures, practices, and techniques that create barriers to a l levia t ing and/or w o r k i n g w i t h i n the tensions and impede the achievement o f o p t i m u m mental health for A b o r i g i n a l people, and 4. generate recommendat ions concerning the role o f nurs ing i n contr ibut ing to mental health p o l i c y . Importantly, I entered the study with the assumption that a tension or tensions existed and discussed this with the participants (see Chapter Four). This assumption of course, was at the heart of the research question and I needed to see what the participants thought about this view. In most cases, this question led to lengthy discussions about the essence of the tension from the perspective of each of the participants, revealing the complexity of what I was setting out to do. 9 T o address these objectives, methods inc luded in-depth i n d i v i d u a l in terviews w i t h p o l i c y makers, both A b o r i g i n a l and n o n - A b o r i g i n a l ; A b o r i g i n a l people w o r k i n g i n the mental health field and related f ie lds; and nurses w o r k i n g i n a hospi ta l setting. A focus group in terview was conducted w i t h health care providers w o r k i n g w i t h A b o r i g i n a l and non-A b o r i g i n a l people w i t h mul t ip le health issues, i nc lud ing menta l heal th and substance abuse. In addi t ion, a rev iew/ cr i t ique o f several current mental health po l i c i e s was conducted. It was anticipated that this k i n d o f c r i t i ca l interpretive inqui ry w o u l d p rov ide a text to identify and clarify the nature o f the tensions and disjunctures. Organization of the Dissertation The present chapter has p rov ided an introduct ion to the research top ic and specific purpose. T h e remainder o f the dissertation is organized around a central l ine o f argument, w h i c h illustrates h o w dominant ideologies , mental health discourses, and everyday practices w i t h i n mental health intersect to shape the tensions and disjunctures be tween A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. Chapter T w o addresses the his tor ical and current context o f the tensions and disjunctures, par t icular ly as they have influenced the mental health o f A b o r i g i n a l peoples. I examine h o w c o l o n i a l ideologies and practices as l i v e d out i n the his tory o f Indian socia l and health p o l i c y continue to shape the col lec t ive consciousness o f the dominant culture i n this country, and influence relationships between A b o r i g i n a l and n o n - A b o r i g i n a l peoples. T h i s provides the backdrop against w h i c h to examine the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to menta l heal th and i l lness and the current mental health system. 10 Chapter Three outlines the theoretical foundations o f this w o r k . Pos i t ioned w i t h i n a cr i t ica l interpretive f ramework that draws o n pos tcolonia l perspectives, I delineate the theoretical v iewpoin ts that influence m y understanding o f Canada ' s c o l o n i a l history, race relations, cu l tura l i sm, difference, and racia l iza t ion. These emerge as key analyt ic constructs i n this study. I also draw o n the perspectives o f A b o r i g i n a l scholars w h o have cr i t iqued these theoretical perspectives i n terms o f their relevance and appl icab i l i ty , and introduce the concept o f "cul tural safety" as a pos tcolonia l interpretive lens i n this study. In Chapter Four , I present the research methodology. I discuss the procedures used to sample participants, col lec t and analyze the data, and main ta in scient i f ic r igor. T h i s chapter also includes a ref lexive analysis o f h o w m y socia l and professional pos i t ion ing has shaped a l l stages o f the research process. Chapters F i v e , S i x , and Seven present the empi r i ca l f indings o f this research. In Chapter F i v e , I examine h o w the ideologies o f paternal ism, ethnocentr ism, and impart ia l i ty shape the tensions or disjunctures. In Chapter S i x , I focus o n the media t ing role o f mental health institutions and pol ic ies , as they provide a point o f intersection between dominant culture ideologies and everyday practices w i t h i n the mental health complex . In Chapter Seven, I shift the analysis to the dynamics o f everyday practices w i t h i n the mental health c o m p l e x that act as barriers to access to mental health care for A b o r i g i n a l peoples. U s i n g examples from m y in terv iew data and fieldnotes, I examine h o w the legacy o f co lon i a l i sm w i t h its assumptions about A b o r i g i n a l peoples, culture, and difference continue to be in terwoven and reproduced i n the everyday experience o f A b o r i g i n a l peoples accessing mental health services. 11 Las t ly , i n Chapter E i g h t , I reconsider the f indings i n l ight o f the theoretical perspectives i n fo rming this research. In the process, I put forward recommendat ions for fostering the development o f c r i t i ca l perspectives and cr i t i ca l consciousness i n the health care sector pertaining to practice, research, and p o l i c y as strategies for i m p r o v i n g access to mental health care for A b o r i g i n a l peoples. 12 C H A P T E R T W O TENSIONS A N D D I S J U N C T U R E S W I T H I N A N H I S T O R I C A L C O N T E X T In this chapter, the literature is rev iewed to prov ide an his tor ica l and current context i n w h i c h to examine the tensions and disjunctures that exist between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. T o situate the mental health concerns o f A b o r i g i n a l people i n a wider social context, I begin by p rov id ing a b r i e f o v e r v i e w o f the soc ia l determinants o f menta l heal th and indicators. A cr i t i ca l examina t ion o f the ep idemio log ica l profi les o f A b o r i g i n a l mental health provides an o v e r v i e w o f the current mental health status o f A b o r i g i n a l peoples i n the context o f soc ia l , economic , and h is tor ica l influences. N e x t , I move o n to examine the history o f Indian soc ia l p o l i c y and h o w the legal relations established by the Indian Act, 1876, have p rov ided the foundat ion for the tensions and disjunctures that exist between A b o r i g i n a l peoples and the mental health care system. These perspectives il lustrate h o w co lon ia l ideologies and practices from the past continue to shape institutions, po l ic ies , and practices; they stand as a reminder o f the co lon ia l past and the neoco lon ia l present ( O ' N e i l , 1989). T h e n I examine the his tor ica l development o f relations o f paternal ism, mistrust, and dependency i n menta l health care i n v o l v i n g A b o r i g i n a l peoples i n Canada . A s I argue i n subsequent chapters, understanding the his tor ica l and s t ructura l 1 1 contexts i n w h i c h menta l health care is del ivered is cr i t ica l to understanding the 111 use the term "structural" in the same way as Browne (2003) to refer to those essential structures in society -"the state, the polity's social and economic status, local and global political economies, globalization and racialization, and dominant institutions including health, legal, educational and government systems - that define, determine and reproduce unequal power relations, racialization, class, and patriarchy as a basis for social relations" (p. 10). Choices available to "social subjects" are impinged upon and determined by those structural formations and social relations. In this way, the interests of some members of society are constrained, while others, usually the dominant cultural group, are privileged (Roman & Apple, 1990, p. 42). 13 issues o f access for A b o r i g i n a l peoples. In this v e i n , I p rovide an examina t ion o f residential school ing and board ing homes as a means o f locat ing the menta l health issues o f many A b o r i g i n a l peoples. T h e focus then shifts s l ight ly to self-governance, p r o v i d i n g a current context for the health and heal ing o f A b o r i g i n a l peoples i n Canada. Here, I br ief ly examine the status o f health transfer arrangements and the importance o f self-governance to the future mental health o f A b o r i g i n a l peoples. I c lose by p r o v i d i n g an examina t ion o f the structure o f menta l health reform w i t h its consequent po l ic ies and services to provide a current context for the tensions and disjunctures. Thus , the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system are brought into focus w i t h i n this particular po l i t i ca l and h is tor ica l per iod. Contemporary Determinants of Aboriginal Mental Health A l t h o u g h d isempowerment has received li t t le attention as a determinant o f health, it is k n o w n that perce ived lack o f power and responsibi l i ty contributes to a dependency mindset and further exacerbates the power imbalances produced by po l i t i c a l margina l iza t ion (Pont ing, 1997). A s ment ioned i n Chapter One , "anomie" is a te rm co ined by D u r k h e i m to refer to " a state o f pervasive demora l iza t ion related to the b r eakdown o f the m o r a l order i nc lud ing re l ig ious , k in sh ip and other social institutions such as the f ami ly unit ; suicides due to such soc ia l b reakdown and normlessness, he termed ' a n o m i e ' " (K i rmaye r , 1994, p. 23). 14 A n o m i e is considered to be one o f the leading causes o f suicide, depression, anxiety, substance abuse, and despair i n A b o r i g i n a l populations today (Brant , 1993; K i r m a y e r ) . F r o m the p re l iminary findings o f a r ev iew o n A b o r i g i n a l health, i nc lud ing the R o y a l C o m m i s s i o n o n A b o r i g i n a l Af fa i r s and the Canad ian Standing Commi t t ee o n Hea l th , Brant (1994), identifies the f o l l o w i n g mental health issues i n the A b o r i g i n a l communi ty : widespread substance abuse, i n c l u d i n g a lcohol , solvent inhalat ion, street drugs, and prescript ion medicat ions; f ami ly v io lence , i nc lud ing spousal assault and the sexual and phys ica l abuse o f ch i ld ren ; and depression and hopelessness, often cu lmina t ing i n suicide. These issues are ident i f ied consistently across many A b o r i g i n a l communi t ies i n Canada (Chandler & L a L o n d e , 1998; Cooper , 1995; Rah im-Jama l , 1998; E l i a s & Greyeyes , 1999; Jodoin , 1997; K i r m a y e r , 1994; K i r m a y e r , Brass, & Tai t , 2000) . Despite cont inued resistance by many to the imposed institutions and be l i e f systems o f the dominant Wes te rn culture, and "despite the brave (or stubborn) unwi l l ingness o f some A b o r i g i n a l people to abandon tradit ional ways, a l l Indigenous cultures were weakened as a result o f their encounters w i t h n o n - A b o r i g i n a l society" ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1995, p. 26) . T h e "culture o f v io lence" enacted by the Canad ian state o n A b o r i g i n a l people 's cul tural identi ty, self-concept, and socia l roles has taken its t o l l . In the 1993 R o u n d Table d iscuss ion o f the R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , D r . C la re Brant specif ical ly ident i f ied poverty, despair, poor housing, and po l i t i c a l a l ienat ion as the root causes o f the traumatic mental health problems that plague many A b o r i g i n a l communi t ies ( O ' N e i l , 1993b). 1 2 This is in contrast with "altruistic" suicide which is done "for love of one's country, nation, family or other organization" or "egoistic" suicide which is done "when life no longer has meaning in terms of the meaning of existence for the individual" (Brant, 1993, p. 62). Suicide in Aboriginal communities may occur as a consequence of any of these, however, "anomie" suicide, which results from a lack of regulatory factors in one's life, is thought to be a significant factor in the suicides of many First Nations people. 15 Current soc ia l status indicators for A b o r i g i n a l peoples are w e l l documented and demonstrate major discrepancies i n compar i son to n o n - A b o r i g i n a l people. F o r example , i n 1999, the Fi rs t Na t ions infant morta l i ty rate, a good barometer o f soc ia l condi t ions and health, was 1.5 t imes higher i n F i rs t Na t ions than the Canad ian infant mor ta l i ty rate ( I N A C , 2002) and i n B C , was 2.2 t imes higher for Indian babies than for other babies between 1991-1999 ( V a n c o u v e r / R i c h m o n d Hea l th B o a r d , 1999). In V a n c o u v e r and R i c h m o n d , the l ife expectancy for status Indian people i n 1997 was 16 years lower than for other people l i v i n g i n these cities ( V a n c o u v e r / R i c h m o n d Hea l th Board) . Age-s tandardized morta l i ty rates from a l l causes for status Indians between 1991-1999 was 1.7 t imes higher than for other B C residents ( V a n c o u v e r / R i c h m o n d H e a l t h Board) . M o r t a l i t y is k n o w n to be s ignif icant ly related to socia l class (Evans , 1993, p. 271) and 13 for at least fifty years, poverty has been k n o w n to be a determinant o f health status (Evans, Barer & M a r m o r , 1994; Kr ieger , R o w l e y , Herman , A v e r y & P h i l l i p s , 1993; O ' N e i l & Pos t l , 1994, p. 82) and is evident w i t h i n F i rs t Na t ions populations. F o r example , accord ing to Hea l th Canada statistics, H I V infect ion among A b o r i g i n a l populat ions has increased 9 1 % from 1996 to 1999 ( A I D S A m o n g A b o r i g i n a l s , 2001) and is disproport ionately evident i n A b o r i g i n a l populat ions, i n part icular i n relat ion to A b o r i g i n a l w o m e n ' s rates (Heal th Canada, 2002). S m o k i n g rates are also a larmingly h igh i n A b o r i g i n a l populat ions . D a t a from the Fi rs t Nat ions and Inuit R e g i o n a l Hea l th Survey (Reading, 1999) indicates that 6 2 % o f people w h o self- identif ied as Fi rs t Na t ions smoked as compared to 3 1 % o f other C a n a d i a n s . 1 4 In addit ion, 1 3 Eight out often Aboriginal children live in poverty in the Vancouver and Richmond area (Vancouver/Richmond Health Board, 1999). 1 4 Percentage of smokers among First Nations young adults age 20-24 were as high as 74%. 16 tuberculosis, i n the F i rs t Na t i ons was 8 to 10 t imes that o f the entire C a n a d i a n p o p u l a t i o n 1 3 ( F N I H B , 2001) . Pover ty also undermines self-esteem and self-worth, m a k i n g people more vulnerable to v io lence , a l coho l and other substance abuse, and the r isks associated w i t h these 1 6 ( A b o r i g i n a l Nurses A s s o c i a t i o n , 1996; D i o n Stout, 1997). Wel fa re c o l o n i a l i s m has resulted i n a h igh degree o f unemployment , a h igh dependency o n meager soc ia l assistance payments (Fiske , 1992) and l o w incomes relative to other C a n a d i a n s 1 7 (E l l i o t t & Foster, 1995, p. 103); notably, unemployment has been correlated w i t h mental and phys i ca l i l l health and w i t h early death. M o r e recent data f rom western Canada show that 4 0 % o f u rban A b o r i g i n a l peoples l i ve o n incomes o f less than $10,000 per year (S imard , 2001) . It is w e l l k n o w n that the general prosperity o f a nat ion affects the health status o f its people and that the distr ibution o f income w i t h i n a country is associated w i t h health status ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1996, p. 217) . In addi t ion to these diff icul t ies , despair o n most reserves is heightened b y inadequate h o u s i n g , 1 8 a shortage o f recreation facil i t ies, and inadequate e d u c a t i o n a l 1 9 and health 1 5 Tuberculosis is correlated with overcrowded housing and poverty (FNIHB, 2001). 1 6 Suicide also has been widely recognized as related to socioeconomic class (Brant, 1993, p. 59) and alcohol and substance abuse (FNIHB, 2003b). 1 7 In 1996, the unemployment rate for First Nations people was almost three times higher than the Canadian rate (FNIHB, 2001). For 1997-1998, the unemployment on First Nations reserves stood at about 29% compared with a rate of 10% for Canada as a whole (INAC, 2000). Although income is gradually improving across First Nations peoples, the income levels on reserves in the 1996 Census were only half that of all Canadians (Armstrong, 1999, cited in FNIHB, 2001). 1 8 "Nearly one fifth of Indian dwellings in BC are considered 'crowded' (10 times the rate for the rest of the province) (Elliot & Foster, 1995, p. 103). In 1999, only 56.9% of homes in First Nations communities in Canada were considered adequate (INAC, 2002). 1 9 Few high schools are close to Indian reserves and, as a consequence, many First Nations adolescents find themselves in boarding situations so that they can attend high school. Leaving home is a stressor for some adolescents and their families, especially in the wake of the historical experience of residential schools. 17 facil i t ies. A c c o r d i n g to Joseph (1991), the hous ing cr is is has been exacerbated by the inf lux o f w o m e n (and their fami l ies) whose status has been reinstated through B i l l 3 1 . In relat ion to education, i n 1996 w i t h i n mainstream school ing , i n V a n c o u v e r , less than 2 0 % o f self-iden t i f i ed 2 1 A b o r i g i n a l students w h o finished grade eight graduated w i t h a h i g h school d i p l o m a and i n R i c h m o n d , 4 0 % graduated i n contrast to 8 0 % o f other youth . Th i r ty percent o f A b o r i g i n a l youth do not even make the grade 8-9 transi t ion ( V a n c o u v e r / R i c h m o n d Hea l th Boa rd , 1999). Epidemiological Constructions of Mental Health and Illness Current mental heal th indicators for A b o r i g i n a l peoples demonstrate major discrepancies i n their menta l health status compared w i t h other Canadians . F o r example, ' in jury , ' 2 3 w h i c h inc ludes a l l forms o f accidental death (unintent ional injury), homic ide , and suicide, accounts for 85.5 % o f a l l deaths i n Firs t Na t ions people aged 15 to 24 years o f age 2 0 One of the most oppressive and controversial aspects of the Indian Act was the enactment of patriarchal state ideology, which until the 1985 amendments to the Indian Act stripped women and their children of their status upon marrying non-Indian or non-status Indian men. These amendments, known commonly as Bill C-31, allowed women who had previously lost their status to regain status. Consequently, after 1985, many women returned to the reserve (Stevenson, 1999). 2 1 "Aboriginal staff in the school system are clear that there is low reporting of ancestry as students or their family chose not to self-identify. Once self-identified, students are treated differently and some believe this increases the possibility of their being discriminated against by teachers and other students. There is also a belief that Aboriginal students are readily labeled as 'special need' because this increases funding to the designated school" (Vancouver/Richmond Health Board, 1999, p. 20). 2 2 Although epidemiological data can be useful in drawing attention to the most pressing mental health needs of Aboriginal peoples, mental health data also can represent "systems of surveillance", which have been instrumental in determining public understandings of Aboriginal peoples and communities (O'Neil, 1993b, p. 34). As O'Neil, Reading and Leader (1998) state: Epidemiological knowledge constructs an understanding of Aboriginal society that reinforces unequal power relationships; in other words an image of sick, disorganized communities can be used to justify paternalism and dependency" (p. 230). Epidemiological constructions of risk factors for cervical cancer among Aboriginal women provide a case in point (Browne & Smye, 2002). 2 3 The majority of Aboriginal deaths from injury are the result of motor vehicle accidents (with alcohol as a major contributing factor), drownings, house fires, and gunshot wounds. Such injuries are considered preventable in about nine cases out of ten (Royal Commission on Aboriginal Peoples, 1996b). 18 and for 5 9 % o f deaths a m o n g those Firs t Na t ions people aged 25 to 44 years ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1996b, p. 153). In B C , the suic ide ra te 2 4 alone is approximately 80 per 100,000 males (Nat ive) as compared to 57.8 per 100,000 males (Native) for a l l o f Canada and 22.8 per 100,000 males (non-Nat ive) . F o r females, the rate is 19 per 100,000 (Nat ive) compared to 14.5 per 100,000 (Nat ive) for a l l o f Canada and 6.4 per 100,000 (non-Nat ive) . Thus Fi rs t Na t ions you th are two to three t imes more l i k e l y to commi t suicide than their non-Na t ive counterparts. Trag ica l ly , for males the highest rate o f suicide occurs i n the 20-24 age group and for females i n the 15-19 age group (E l l io t t & Foster, 1995). A l s o , adolescent males are s ix t imes more l i k e l y to c o m m i t suic ide than adolescent females (p. 109). T h e h i g h suic ide rates i n Fi rs t Na t ions you th and young adults are part icularly a l a rming g iven that approximately 6 6 % o f Canada ' s registered Firs t Nat ions people are under 35 years o f age (p. 9 8 ) . 2 6 H o w e v e r , it shou ld be noted that these statistics should not be broadly v i e w e d as an accurate ref lect ion o f a l l F i r s t Na t ions communi t ies (Chandler & L a L o n d e , 1998; Chartrand, 1995). F o r example , one B C study showed that suicide rates across the 196 bands studied var ied considerably: O v e r one h a l f o f the bands (111) experienced no youth suicides at a l l over the pe r iod o f study (1987 to 1992), whereas, at the other end o f the cont inuum, some The suicide figure would be even higher if mysterious and accidental death were included given that many of these are thought to disguise suicide (Brant, 1993; Cooper, 1995; Kirmayer, 1994; Warry, 1998). 2 5 "Reliable statistics are not available because there is some difficulty in documenting the actual incidence of suicide in Aboriginal populations, since non-status Indians may not be included in some statistics" (Brant, 1993, p. 55). However, Cooper (1995) reports some confidence in a study conducted by the BC Institute on Family Violence which found the same rates of suicide as those obtained in earlier studies using data collected from coroner's reports, including in-depth reviews of those reports. Also the study findings "were congruent with literature in documenting geographic variability when Aboriginal population size is high and underline previous warnings that rates calculated on small population bases may be very misleading" (Cooper, p. 211). 2 6 A statistic that supports the idea of focusing suicide health promotion/prevention activities on children and youth (Royal Commission on Aboriginal Peoples, 1995). 19 bands had extremely h i g h ra tes 2 7 (Chandler & L a L o n d e , p. 214). These differences were found to be related to the extent to w h i c h markers o f "cul tura l cont inui ty" were present i n the g iven communi ty . These "protect ive factors" inc luded land c l a i m negotiations, self-government, educat ion services, po l ice and fire services, health services, and cul tural facil i t ies. In another study conducted i n B C , i t was found that A b o r i g i n a l suic ide rates were higher for on-reserve populat ions than for off-reserve populat ions and that characteristics o f reserve populat ions such as " l o w e r levels o f educa t ion , 2 9 household c rowd ing , less employment , more s ingle parents and fewer elders, are associated w i t h higher suicide rates" (Cooper , 1995, p. 220). A b o r i g i n a l people who c o m m i t suicide are also l i k e l y to have a higher number o f adverse l i fe history indicators than non-Abor ig ina l s w h o c o m m i t suicide, i nc lud ing "higher rates o f f a m i l y and personal a l coho l abuse, and/or phys i ca l o r verbal v io lence either as a v i c t i m or as a perpetrator." A l s o , they were "more l i k e l y to be intoxicated at the t ime o f the suic ide , more l i k e l y to use hanging and l i k e l y to act impu l s ive ly , or at least wi thout overt warn ing . It was rare for A b o r i g i n a l ind iv idua l s w h o commi t t ed suic ide to have consul ted a health professional , whereas almost h a l f the non-Abor ig ina l s had done so" (p. 220). A c r o s s the literature o n A b o r i g i n a l suicide, it is a generally he ld v i e w that suicide occurs w i t h a la rming frequency i n some Firs t Na t ions communi t ies and that many suicides 2 7 High rates are often an artifact of a cluster of suicides. 28 Although these findings do not suggest that the markers are causal mechanisms in terms of better mental health outcome (i.e., lower suicide rates), they do suggest that these markers are related in some way to differences in mental health status across First Nations communities, and are worthy of further investigation. 2 9 However, Kirmayer (1994) reports that First Nations people who committed suicide tended to be better educated themselves. It is hypothesized that they are acutely aware of the problems surrounding them in relation to a lack of employment opportunities, and so forth. 20 c o u l d have been prevented (Brant , 1993; Cooper , 1995; K i r m a y e r , 1994). M o s t feared is the 30 cluster o f suicides that have occurred as a consequence o f the contagion effect, w e l l documented i n the suic ide literature. Su ic ide and other forms o f v io len t death are symptomatic o f marg ina l iza t ion and the his tor ic domina t ion w h i c h has l ed to the chronic hopelessness and intergenerational despair experienced by many A b o r i g i n a l communi t ies (Brant , 1993; Chand le r & L a L o n d e , 1998; Cooper , 1995; K i r m a y e r , 1994; R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1995, 1996b; War ry , 1998). T h e pervasiveness o f a lcohol and drug abuse casts a s imi la r shadow over the l ives o f A b o r i g i n a l peoples and is often impl ica ted i n v io lence and petty cr imes that a l l too often result i n incarcerat ion (Duran & Duran , 1995, 2000; W a l d r a m , He r r i ng , & T K Y o u n g , 1995; W a l d r a m , 1997; W a d e , 1995). In her research i n the central interior o f B C , Furniss (1999) found that status domina t ion often featured as the forcible ascr ipt ion o f negative identities to A b o r i g i n a l peoples - the mos t c o m m o n being the "drunken Indian." A c c o r d i n g to Furniss , the ' d runken Indian ' stereotype features so pervasively that, o n occas ion , sober A b o r i g i n a l people have been perce ived by Euro-Canadians as drunks (p. 129). Furniss found that many Euro-Canadians continue to define the problems that A b o r i g i n a l peoples face as t ied to socia l i l l s : "unemployment , poverty, a l coho l i sm, and poor l i v i n g condi t ions" separate f rom the soc ia l , economic , and h is tor ica l inequalit ies that d iv ide A b o r i g i n a l and Euro -Canad ian populat ions. She found that many people offered s impl i s t i c solut ions to these problems; for example , " A b o r i g i n a l people must develop the w i l l to go out and f ind w o r k " (pp. 151-152). It w o u l d seem that, for many, these problems w o u l d be so lved i f the values o f dominant culture were adopted (p. 152). 3 0 "For example, in Davis Inlet, 46 persons out of a population of 500 had attempted suicide during a single year" (Warry, 1998, p. 145). 21 There is tremendous var iabi l i ty i n a lcohol abuse across A b o r i g i n a l communi t ies . It has been estimated that 50 -80% o f some adult populat ions have alcohol-related problems. Factors associated w i t h substance abuse include "phys ica l and geographic isola t ion, unemployment , and l ack o f recreational opportunit ies" - c o m m o n features o f Nor the rn communi t ies i n general, and N a t i v e communi t ies i n part icular (War ry , 1998, p . 78). Excess ive a l coho l use i n w o m e n can cause Fetal A l c o h o l Syndrome ( F A S ) or Feta l A l c o h o l Effects ( F A E ) across both n o n - A b o r i g i n a l and A b o r i g i n a l populat ions. T h e prevalence o f a lcohol abuse among A b o r i g i n a l ch i ldren and youth is u n k n o w n , however , i n many A b o r i g i n a l communi t ies , gas sniff ing has become a significant issue i n v o l v i n g up to 30 -40% o f the youth i n some Nor the rn areas (Warry , 1998). Other substance abuse remains wor r i some i n some communi t ies . F o r example , i n the 1996 Nor thwes t Terr i tor ies A l c o h o l and D r u g Survey ( N T B S ) , i t was found that A b o r i g i n a l people 15 years and older were almost three t imes more l i k e l y to have used marijuana or hashish i n the previous year than n o n - A b o r i g i n a l residents and three and a ha l f t imes more l i k e l y to have used L S D , speed, cocaine, "c rack ," or he ro in ( N T B S , 1996). It has been found that cu l tu ra l ly relevant programs, w h i c h emphasize tradit ional A b o r i g i n a l values, tend to be the most successful treatment approaches ( W a r r y & Moffat t , 1993; War ry , 1998; Westermeyer & Neider , 1984). Today , domest ic , sexual , and other forms o f v io lence continue to be ci ted as one o f the most pressing issues fac ing A b o r i g i n a l communi t ies ( A b o r i g i n a l Nurses A s s o c i a t i o n , 2002; Ontar io N a t i v e W o m e n ' s Assoc ia t ion , 1989). L a R o c q u e (1993) argues that the a la rmingly h igh rates o f domest ic and sexual v io lence experienced b y A b o r i g i n a l w o m e n and ch i ld ren are "one o f the most problemat ic legacies o f long- term c o l o n i z a t i o n " (p. 74). A l t h o u g h evidence about inc idence rates is generally l ack ing , front-l ine workers and 22 community members identify abuse as a significant concern (Jodoin, 1998; Waterfall, Joseph & VanUchelen, 1994). 31 LaRocque (1993) draws attention to the ease with which institutions and organizations/ agents of the dominant culture - for example, the media, the justice system, the police, and the social service sector - mistakenly attribute violence and sexual abuse as Aboriginal cultural traits rather than "social conditions arising from societal negligence and policies" (p. 76). In response to this problem, Turpel (1993), an Aboriginal lawyer and scholar, has reframed the term "culture of violence" to include the effects of colonization perpetrated by the state on Aboriginal women's identity, self-concept, and social roles, in recognition of the broader historical and sociopolitical context of violence. In this regard, Warry (1998) includes the effects of what he calls "native child abuse by the child welfare system" (p. 81). Family violence and, in particular, neglect and/or abuse of children, are often attributable to "highly stressful environments" usually created by a combination of social, economic, and health conditions. The synergistic effects of unemployment and poverty contribute to the proliferation of unmet human needs, social pathologies, and high rates of family violence (Dion-Stout, 1997; Young, 1994). As noted earlier, poverty undermines self-esteem and self-worth making women32 more vulnerable to violence, alcohol and substance abuse, and the risks associated with each of those (Aboriginal Nurses Association, 1996; Dion-Stout, 1996, 1997). 3 1 Here I use the term "institutions" like Henry, Tator, Mattis, and Rees (2000) to refer to those systems that are foundational to the Canadian state including education, the media, the arts, policing, the justice system, human services, and corporate and government systems. 3 2 Women and children are most often the victims of family violence, often attributed to alcohol and/or drug abuse (Aboriginal Nurses Association, 2002; Turpel, 1993). 23 A l t h o u g h the number o f A b o r i g i n a l ch i ld ren l i v i n g o n reserves w h o are ' i n care' has decreased, the percentage is s t i l l above the nat ional average. In M a r c h 1999, about one h a l f o f V a n c o u v e r ch i ld ren " i n care" were A b o r i g i n a l (48%: 638/1329) . " T h e r i sk factors that contribute to placement o f ch i ld ren i n care include single parent fami l ies , soc ia l i solat ion, poverty, and drug and a lcoho l abuse" ( V a n c o u v e r / R i c h m o n d H e a l t h B o a r d , 1999, p. 24). The major cause o f apprehension o f ch i ld ren by socia l welfare agencies varies, however , the most c o m m o n reason relates to v io lence and neglect i n the home, often attributable to a lcohol use ( V a n c o u v e r / R i c h m o n d Hea l th Board) . The prevalence o f serious mental illness is less w e l l documented i n A b o r i g i n a l populations i n Canada . The f indings o f a 1999 p o l l o f mental heal th c l i n i c services suggests that approximately 3 .3% o f the popula t ion accessing mental heal th services i n the Vancouve r and R i c h m o n d areas are Fi rs t Na t ions people (R . Peters, personal communica t ion , Ju ly 15, 1999 and N o v e m b e r 12, 2003). H o w e v e r , between 1992-1998, far fewer A b o r i g i n a l people than anticipated accessed services at the R i v e r v i e w H o s p i t a l . 3 3 A c c o r d i n g to the V a n c o u v e r / R i c h m o n d Hea l th B o a r d (1999): " I f psychot ic condi t ions occur at rates s imi la r to the general popula t ion, then the 1-1.5% A b o r i g i n a l admissions to R i v e r v i e w suggests about one-third o f A b o r i g i n a l people w h o require care actually receive i t " (p. 33). Popula t ion estimates suggest that approximate ly 4 % o f the popula t ion i n l ower ma in l and B C are A b o r i g i n a l . Howeve r , generally, l i t t le is k n o w n about the numbers o f A b o r i g i n a l people w h o access mental health services because the designation o f " A b o r i g i n a l " is not sought when health care is accessed and on ly persons w i t h "status" can be ident i f ied. In addi t ion, mental health informat ion systems are not w e l l established i n B C . A psychiatric tertiary care facility in BC. 24 In addi t ion to the issues above, there is an overrepresentation o f A b o r i g i n a l people i n federal and p r o v i n c i a l pr isons across Canada, w i t h the highest percentage o f people incarcerated i n the prair ies (Mon tu re -Angus , 2000 ; W a l d r a m , 1997). T o shed l ight on this issue, the A b o r i g i n a l Just ice Inquiry o f M a n i t o b a commented: Cu l tu r a l oppression, soc ia l inequali ty, the loss o f self-government and systematic d i sc r imina t ion , w h i c h are the legacies o f the Canad ian government ' s treatment o f A b o r i g i n a l people, are inter twined and interdependent factors. ( H a m i l t o n & Sinc la i r , 1991, p . 86, c i ted i n W a l d r a m , 1997, p. 22) D i s c r i m i n a t i o n and oppression, i n va ry ing forms, are strongly imp l i ca t ed i n this dramatic overrepresentation ( M o n t u r e - A n g u s ; W a l d r a m ) . F o r example , A b o r i g i n a l people are more l i k e l y to be charged w i t h mul t ip l e offences than n o n - A b o r i g i n a l people , and receive longer sentences, and less l i k e l y to receive absolute or condi t iona l discharges (Montu re -Angus ) . A l t h o u g h the large numbers o f A b o r i g i n a l peoples i n the penal system has been the central focus o f "every j ustice inqui ry mandated i n the last three decades. . . no c o m m i s s i o n or inqui ry has managed to m o v e beyond this f ixa t ion w i t h numbers" (Mon tu re -Angus , p. 369). D r a w i n g o n the experience o f psychologists and other menta l health professionals, W a l d r a m (1997) asserts that the long-term trauma "that f lows f rom c o l o n i a l i s m and oppress ion" exper ienced by many A b o r i g i n a l ind iv idua ls and societies has had profound consequences for "bo th i n d i v i d u a l and col lec t ive behaviour"(p. 43) . T h e narratives i n his interviews w i t h A b o r i g i n a l p r i son inmates reveal the significant disrupt ive role o f long-term trauma (often beg inn ing i n ch i l dhood , and notably v io lent for some) i n many o f the inmates l ives . Howeve r , the current Wes te rn mental health assessment and diagnost ic categorizations fa i l to recognize the profound effects o f co lon iza t ion , for example , group trauma, o n mental 25 health w i t h the risk o f subsequent inappropriate treatment o f "pa tho log ica l behaviours ," for example, incarcerat ion, (Duran & Duran , 1995; Wald ram) . T h e mental heal th inequit ies o f A b o r i g i n a l peoples cannot be glossed over as l ifestyle, behavioura l , or cul tural issues, rather, they are manifestations o f the his tor ical , soc ia l , po l i t i c a l , and economic determinants inf luencing menta l health status and access to equitable health care. In the f o l l o w i n g section, I locate the tensions and disjunctures i n their h is tor ica l context. Locating Tensions and Disjunctures: Assimilation T h e his tory o f Canada is a history o f the co lon iza t ion o f A b o r i g i n a l peoples, and c o l o n i a l i s m continues to dominate and subjugate A b o r i g i n a l peoples i n many ways even today. A s L a R o c q u e (1996) states C o l o n i z a t i o n is a pervasive structural and psycho log ica l re lat ionship between the co lon ize r and the c o l o n i z e d and is ul t imately reflected i n the dominant institutions, pol ices , histories, and literatures o f occupying powers . . .The tentacles o f co lon i za t i on are not o n l y extant today, but may also be m u l t i p l y i n g and enc i rc l ing N a t i v e peoples i n ever-tighter grips o f landlessness and marg ina l iza t ion , hence, o f anger, anomie , and v io lence . . . (pp . 11-12) E a r l y i n the c o l o n i z a t i o n process an assimilat ionist ethos preva i led i n w h i c h A b o r i g i n a l peoples as "wards o f the state" were to be assimilated into the fabric o f Canad ian society. In its earliest beginnings , i m p e r i a l i s m and the process o f co lon iza t ion w o u l d set the tone and tenor o f Indian soc ia l [and health] p o l i c y (Smi th , 1999). T h e systematic subjugation o f A b o r i g i n a l peoples has its or ig ins i n the co lon ia l laws and po l ic ies enacted upon A b o r i g i n a l peoples i n 1876 i n the Indian Act. W h i l e this framework was premised o n the pretext o f 26 assisting Indians, the under ly ing intention to c i v i l i z e and el iminate "Indians" is made clear i n the words o f S i r J o h n A . M a c d o n a l d (1887): "The great a i m o f our c i v i l i z a t i o n has been to do away w i t h the t r ibal system and assimilate the Indian people i n a l l respects w i t h the inhabitants o f the D o m i n i o n , as speedily as they are fit for the change" ( M i l l e r , 1989, p. 189). T h i s was further elaborated i n 1920 by D u n c a n C a m p b e l l Scott, Depu ty Superintendent o f Indian Af fa i r s as f o l l o w s : " . . . O u r object is to continue un t i l there is not a s ingle Indian i n Canada that has not been absorbed into the body po l i t i c and there is no Indian question and no Indian Depar tment . . . (Les l i e & M a c G u i r e , 1979, p. 114; c i ted i n Ca i rns , 2001 , p. 17). T h e ass imila t ionis t intent o f the Act was pursued at many levels : A b o r i g i n a l lands were appropriated and reserves established; residential schools were instituted w i t h the goal o f indoctr inat ing ch i ld ren into the dominant culture - a col laborat ive effort between church and state; and, cul tura l spir i tual practices were out lawed. In fact, the Act gradual ly took control o f most aspects o f l i fe , i n c l u d i n g health services; welfare; taxes; l i v e l i h o o d , i nc lud ing hunting and fishing rights; c i t izenship , i nc lud ing the right to vote; o rgan iza t iona l 3 4 / r u l i ng structures; and, "even the r ight to loi ter i n a p o o l r o o m " ( M o r a n , 1999, p. 20). The consumpt ion o f a lcohol was also prohibi ted . In addi t ion to these devastating social changes, the government designat ion o f " Indian" became one o f the most d iv i s i ve and destructive aspects o f the Indian Act. First , it d iv ided the Canad ian A b o r i g i n a l peoples, the Firs t Na t ions , Inuit, and M e t i s , into an arbitrary but devastating class structure. Secondly , it created a sch i sm between some reserve and urban 3 4 Even potlatching was outlawed. Traditionally, this was central to the whole concept of status and rank, and played a pivotal role in the social organization of the community. Because there was no writing system, the potlatch "served to publicly recognize an individual's claim to a particular status of inherited right. It also served an economic role, redistributing food and goods" (McMillan, 1995, p. 204). Today, potlatching remains an important aspect of community life for many West Coast people, although with somewhat different meanings than in earlier times. 27 populat ions. Cur ren t ly , i n several A b o r i g i n a l communi t ies , this s c h i s m has been widened because o f recent l eg i s la t ion (2002) w h i c h permits off-reserve people to vote i n on-reserve elections. T h i r d l y , the Act assisted i n fuel ing the d iv ide a long l ines o f gender. U n t i l 1985, when the Act was repealed ( B i l l C-31) , A b o r i g i n a l w o m e n and their ch i ld ren were stripped o f their status upon mar ry ing non-Indian or non-status Indian men. S ince the repeal , many A b o r i g i n a l w o m e n and ch i ld ren have c l a i m e d their status as "Indians," however , return has not a lways been easy for them and i n some A b o r i g i n a l communi t ies / reserves, they have not been accepted 3 5 (Fleras & E l l i o t t , 1992). D i s c r i m i n a t i o n based o n gender has had cont inuing effects and has "scarred many A b o r i g i n a l communi t ies . " A s L a R o c q u e (1996) states, " R a c i s m and s ex i sm together result i n powerful personal and structural expressions i n any society, but they are c lea r ly exacerbated under co lon ia l condi t ions" (p. 15). Four th ly , amendments to the Indian Act i n 1884 and 1885 ou t lawed the ceremonial activit ies associated w i t h the potlatch, or feast, among Nor thwes t Coas t cultures ( W a l d r a m , 1997). H i s to r i ca l ly , the c o l o n i z i n g o f A b o r i g i n a l peoples focused o n the d i smant l ing o f tradit ional ceremonia l practices because o f the perceived central i ty o f such practices to their cul tural existence. These l imi ta t ions were h igh ly protested b y m a n y A b o r i g i n a l communi t ies and therefore became p o l i t i c i z e d w i t h i n the context o f co lon ia l relations. A s a consequence, 3 5 Before the repeal of Bill C-31 women and children could not reside on reserve lands, receive payment of any benefits resulting from treaties, or be buried in a reserve cemetery. In addition, Fiske (1993) explains that "reinstatement of Indian status remains dependent upon male lineage" (p. 16). This kind of treatment, coupled with other discriminatory practices, such as the denial of property rights, directly affected women's capacity to support themselves and their families, contributing both to their economic marginalization and to welfare colonialism (Browne, 2003; Fiske, 1993). 3 6 For example, male-dominated Band councils frequently sided against women and with the Canadian government in the belief that to do otherwise would undermine the Crown's trust responsibility for Aboriginal people" (Turpel, 1989, p. 154). 28 many traditional healing practices went underground. According to Waldram, the Act served 37 to alienate Indigenous peoples from their "land, labour and resources" (p. 5). Lastly, the Indian Act created a divide between levels of government, federal and provincial, which has resulted in continued jurisdictional debates regarding who has responsibility for the social and health concerns of Aboriginal peoples, profoundly affecting their mental health and well-being. With the enactment of the Act, those who had status were entitled to special rights from the Canadian nation and those who did not became - "a Canadian version of a dispossessed race" (O'Neil et al., 1999, p. 134). Although the British North America Act, 1867, stipulated federal responsibility for health, it provided for a provincial role "in establishing and delivering health services" (O'Neil et al., 1999, p. 146). Regardless, the provinces viewed the British North America Act as clearly setting out federal responsibility for First Nations and Inuit health (and according to O'Neil et. al., in some cases all Aboriginal health programs, except those prescribed by the Canada Health Act for all Canadians). Today, the provinces do provide many services to First Nations peoples through the mainstream service delivery system. The rationale for provincial involvement is Section 87 of the Indian Act, 1951, which states that "[a]ll laws of general application from time to time in force in any province are applicable to and in respect of Indians in the province, except to the extent that such laws are inconsistent with this Act" (Armitage, 1995, p. 82). However, in relation to the health portfolio, this becomes a much muddier issue because of the lack of According to Waldram (1997), it is not clear how many Aboriginal people were incarcerated for practicing banned religious activities, however, it has been suggested through the oral tradition of many Aboriginal peoples, that this was common, "with or without formal charges or convictions" (p. 8). Even with the 'Indian Rights' political movement post World War I, repeals of the Indian Act were not successful until 1951. By that time, the criminalization of Aboriginal spirituality had already taken its toll. 29 regulat ion o f health (and c h i l d welfare) accorded i n the Indian Act. Irrespective o f the health and c h i l d welfare issues, the province continues to be the c h i e f legis la t ive body for Fi rs t Na t ions services, a perpetuation o f earlier notions o f integrating F i r s t Na t ions services w i t h regular p rov inc i a l services. M e t i s peop le s 3 8 and non-status Indians get caught i n the ju r i sd ic t iona l struggle because the provinces generally d i s c l a i m any responsibi l i ty for them g i v e n their pos i t ion that the federal government i s responsible for a l l non-Canada Health Act matters (Cai rns , 2000). In addi t ion, the F i rs t Na t i ons and Inuit Hea l th B r a n c h ( F N I H B ) ( formerly M e d i c a l Services Branch) does not p rov ide services to non-status Indians and M e t i s , whether l i v i n g i n urban or rural settings. H o w e v e r , recently, the federal government has started to p rov ide some resources for "targeted p r o g r a m m i n g " to the M e t i s and non-status Indians ( O ' N e i l et a l . , 1999, p. 147). O v e r the past several decades, notions o f " integrat ion" and moves to se l f -govern ing 4 0 arrangements have been undermined by an ass imila t ionis t ethos w h i c h , one c o u l d argue, remains t ight ly w o v e n into the fabric o f Canad ian society. A l t h o u g h some progress had been made i n terms o f accord ing A b o r i g i n a l s self-governance, under the guise o f support ing A b o r i g i n a l "autonomy", federal support o f self-government is considered to be mere rhetoric 3 8 The Metis have been referred to as 'The Forgotten People' (Daniels, 1979) or 'The Non-People' (McKay, 1972) because they have most often been virtually ignored by the federal government (Cairns, 2000). 3 9 In Gathering Strength, a federal government response to the recommendations of the Royal Commission on Aboriginal Peoples, all Aboriginal groups were included in the Aboriginal action plan, and strengthening of partnerships across all levels of government was recommended as key to addressing the needs of Metis and of! reserve Aboriginal peoples, including those in urban areas (O'Neil et al., 1999, p. 147). 4 0 Asch (2002) defines self-government as "the ability of a group to govern its land and the people on them by setting aside goals and acting on them without having to seek permission from others" (p. 66). According to Tennant (1990), "The demands for self-government have always been implicit in land claims: in recent years these demands have become prominent and explicit" (p. 13). 30 by s o m e 4 1 (Armi tage , 1995; Fleras & E l l i o t , 1992). T h e deeply-rooted ideologies that were foundational i n the construct ion o f Indian socia l p o l i c y remain . F o r example , the Indian Act continues as the formal basis for Indian po l i cy . In addi t ion, the Indian Af fa i r s B ranch o f the Department o f Indian Af fa i r s and Nor the rn Deve lopment ( D I A N D ) remains the central federal body concerned w i t h F i rs t Na t ions issues. T h e shift i n Indian p o l i c y and administrat ion is p lagued w i t h problems related to deal ing w i t h the remnants o f co lon i z ing practices, the reali ty o f oppos ing parties w i t h compet ing interests and ideologies , and federal-p rov inc ia l ju r i sd ic t iona l issues. In the next section, I examine h o w the history o f p r o v i s i o n o f health care services to A b o r i g i n a l peoples was part and parcel o f the process o f co lon iza t ion , an important feature i n the fostering o f d isempowerment and dependency ( K e l m , 1998). Historical Context of Paternalism in Indian Health Policy C o l o n i a l praxis has situated A b o r i g i n a l bodies at part icular sites o f struggle. . . M e d i c i n e , its perspectives, and its practitioners, have been instrumental i n shaping c o l o n i a l relations, bo th w i t h i n the dominant society through formulations o f c o l o n i a l power , and between the colonizers and their subjects. ( K e l m , 1998, p . 100) A s noted earlier, the history o f dependency o n f ledg l ing services can be traced to the epidemics that devastated A b o r i g i n a l communi t ies dur ing the per iod o f early contact w i t h n o n - A b o r i g i n a l traders, explorers , and settlers ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1996a; W a l d r a m , Her r ing , & Y o u n g , 1995). The Indian Act i n its incept ion was the 4 1 For example, while resources are administered in a manner that permits local decision-making by the band, "what can be permitted can also be withheld" and the exercise of self-government limited by extensive accountability mechanisms (Armitage, 1995, p. 82). 31 enactment o f grand scale c o l o n i a l i s m . T h e gradual appropriat ion o f t radi t ional lands, movement to reserves, prohibi t ions p laced o n hunting and fishing, and marg ina l iza t ion f rom the wage e c o n o m y resulted i n endemic pover ty and forced economic dependence across A b o r i g i n a l communi t i es ( K e l m , 1999; Pont ing , 1997; W a l d r a m et al .) . A relationship o f increased dependency was created by the domina t ion o f A b o r i g i n a l economies , govern ing structures, and loca l l eve l insti tutions by the development and expans ion o f the dominant society 's e conomy and insti tutions, i nc lud ing medic ine ( K e l m , 1998). E v e n for the M e t i s , w h o , l i ke the Inuit, had largely been ignored by the federal government, "paternalistic care" became the n o r m w h e n p r o v i n c i a l government interest ( in A l b e r t a and Saskatchewan) was aroused by the poor soc io -economic condi t ions among the M e t i s i n the 1930s and 1940s (Cairns , 2000) . Status A b o r i g i n a l people became "administered people ," "wards o f the state," w i t h a separate branch o f the federal government devoted to their affairs. In response to the many societal changes threatening their existence, A b o r i g i n a l leaders entered into agreements and treaties w i t h the state a imed at ensuring the su rv iva l o f their people ( R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1996a). Often, l imi t ed food rations and med ica l resources 4 2 were p rov ided to A b o r i g i n a l peoples i n exchange for economic ga in and re l igious convers ion ( B r o w n e , 2003; O ' N e i l & Kaufer t , 1990). H i s to r i c a l l y , the quest ion o f whether the p rov i s ion o f m e d i c a l care pa id for b y the Department o f Indian A f f a i r s is an A b o r i g i n a l right "has been an important fu lc rum around w h i c h the ideo log ica l underpinnings o f the Indian Hea l th Services B r a n c h o f the Department 4 2 Aboriginal medicine was not supplanted by Western approaches; rather, a state of medical pluralism developed in which Aboriginal peoples drew on both Aboriginal and Western medicine to deal with new diseases (Kelm, 1998). Throughout the first decades of contact, early settlers availed themselves of Aboriginal substances and medicines and Aboriginal peoples built medical systems that incorporated new remedies while "maintaining an indigenous base of medical thought" (p. 153). However, it was the processes of colonization, complete with systems of thought that excluded Aboriginal forms of medicine as quackery or superstition, that stifled the cross-cultural exchange (p. 153). 32 o f Indian A f f a i r s have been art iculated" ( K e l m , 1998, p . 100). H o w e v e r , as noted earlier, whether federal health services are considered a treaty r igh t , 4 3 that is h i s tor ica l ly contingent, an inherent right, that i s "based o n the nature o f being human ," or a matter o f p o l i c y 4 4 continues to be debated. B e i n g constructed by the Canad ian state as "wards o f the na t ion" i n need o f be ing " c i v i l i z e d , " A b o r i g i n a l peoples were p rov ided w i t h health services i n the spir i t o f "benign neglect" and "benevolent paternal ism," generally i n the fo rm o f m e d i c a l r e l i e f or cr is is response ( T . K . Y o u n g , 1984). The construct ion o f A b o r i g i n a l people as diseased and their communi ty l i fe as disintegrating, p rov ided the mora l grounding for the 19th century pos i t ion that b r ing ing Wes te rn m e d i c a l science to the A b o r i g i n a l peoples was the right th ing to do 4 5 A s noted earlier, even residential schoo l ing was considered a means o f preserving the health and we l l -be ing o f ch i ld ren w h o required protection from their supposedly "negligent and ignorant parents" ( K e l m , 1998, p. 62) . P rompted by concern about the spread o f contagious disease, i n part icular tuberculosis, to external society, a system o f pr imary care c l i n i c s , a p u b l i c health program, and regional hospitals were instituted by the Canadian state i n the 1930s ( O ' N e i l et al . ,1999; T . K . Y o u n g , 1984). G r o w i n g demora l iza t ion and dependency, however , were reinforced b y services and practices founded o n paternalistic and authoritarian mode ls o f health care _43 The treaty right to health care is usually referred to as the medicine clause in Treaty 6, signed with the Cree of central Alberta and Saskatchewan in 1876 (Kelm, 1998; O'Neil et al., 1999). Negotiators of Treaties No. 8 (1899), 10 (1906), and 11 (1921) were unsuccessful in having similar provisions brought into their treaties (Kelm). 4 4 The official position of the First Nations and Inuit Health Branch of Health Canada (FNIHB), the federal governmental branch responsible for status First Nations and Inuit health, is that health services are a matter of policy, not an "inherent" right (First Nations and Inuit Health Branch, 2003; Health Canada, 1995). 4 5 In fact, by the early part of the 20th century, "allopathic medicine was able to monopolize public resources and the majority of public sympathy in the west" as the only 'scientific' medical tradition (Thorne, 1993). del ivery. In some places this was further heightened by r ac i sm and ju r i sd i c t iona l disputes w h i c h created a barrier to access to treatment ( K e l m , 1998). A c c e s s to treatment often meant that people had to leave their home environment and travel great distances for ca re , 4 6 sometimes remain ing there for extended periods o f t ime. T h i s fostered a g r o w i n g internal c o l o n i a l i s m w i t h its i m p l i c i t message that the treatment o f disease was entirely i n the hands o f the c o l o n i a l power (Browne , 2003; O ' N e i l & Kaufert , 1990) and that E u r o - C a n a d i a n doctors and nurses were super io r 4 7 ( K e l m , 1998). W i t h the advent o f antibiotics and the expansion o f health services i n A b o r i g i n a l communi t ies , morta l i ty and morb id i ty rates o f infectious disease were greatly reduced. However , health status inequities between A b o r i g i n a l and n o n - A b o r i g i n a l peoples persisted (Browne , 2003; T . K . Y o u n g , 1984). M o s t health problems s temmed f r o m extreme poverty, lack o f c lean water and sewage systems, inadequate nutr i t ion and hous ing , and unemployment . B y the 1960s, the concern w i t h infectious diseases, a l though s t i l l endemic i n some areas, was overshadowed by socia l pathologies: mental health concerns such as depression, anxiety, and suicide; h igh infant mortal i ty rates; and, soc ia l p roblems such as a l coho l i sm and f ami ly v io lence ( T . K . Y o u n g , 1994). In keeping w i t h b i o m e d i c a l epis temological assumptions and approaches to health care, soc ia l p roblems were treated as b io logica l ly-based diseases or l ifestyle issues, separate f rom the soc ia l and economic circumstances o f A b o r i g i n a l people, and therefore treatable accord ing to the p reva i l ing 4 6 In particular, this related to the need for treatment of tuberculosis, which placed people in enforced quarantine in 'Indian' hospitals. Notably, Aboriginal and non-Aboriginal populations were usually segregated in hospital and clinic settings prior to the 1950s in BC. 4 7 In no way is this intended to imply that individuals involved in the provision of health care to Aboriginal people were "co-conspirators with the Canadian state," but as Kelm (1998) points out, "The very nature of humanitarianism under colonial relations works to legitimate those relations and the power bases supported by them" (pp. 127-128). 34 med ica l mode l ( O ' N e i l , 1986). T h i s medica l iza t ion discourse has cont inued as one o f the central mediat ing practices w h i c h shapes and is shaped by Wes te rn not ions o f health and i l lness and the everyday practices o f mental health care del ivery . In the f o l l o w i n g section, I provide a b r i e f ove rv i ew o f the h i s to r ica l impos i t i on o f the residential schools (and boarding schools) as legislated through the Indian Act to show h o w A b o r i g i n a l identities and b o d i l y health were further weakened, and their dependency supported. A l t h o u g h residential school ing was not complete ly negative (F i ske , 1996) and the assimilat ionist intent was unsuccessful ( K e l m , 1998), the overa l l impact o f residential schools has been devastating. A s K e l m (1998) states, "[t]his was a pe r iod dur ing w h i c h the cultural hegemony imposed by the c o l o n i z i n g force o f residential s choo l ing shaped A b o r i g i n a l b o d i l y health and representation i n profound w a y s " (p. 57). Colonizing Identities: Intergenerational Trauma M o s t scholars w o u l d agree that European-introduced disease was a major factor i n the catastrophic decl ine i n the N o r t h A m e r i c a n A b o r i g i n a l popula t ion . A b o r i g i n a l people lacked immun i ty to infectious diseases and were therefore appa l l ing ly vu lne rab l e . 4 8 The fact that A b o r i g i n a l traditions have surv ived at a l l is extraordinary, and testifies to their except ional strength and resi l ience (F i ske , 1995; O ' N e i l & Pos t l , 1994). Contac t w i t h European-introduced disease marked the beginning o f A b o r i g i n a l dependence o n the Canad ian state and its f ledgl ing health services. The inscr ip t ion o f disease o n A b o r i g i n a l bodies was not s i m p l y a product o f the 4 8 It is estimated that the pre-contact Aboriginal population in Canada was approximately 210,000 dropping to about 80,000 in 1870 and recovering to 120,000 in the early 1900s (O'Neil, 1993b, p. 29). However, over 30 years ago, William Duff estimated that the First Nations in BC lost 65,395 living individuals in the first 150 years after contact, representing a 74% decline in population (Kelm, 1998). 35 processes o f nature (an idea often propagated b y those i n authority), but a lso a direct consequence o f the process o f co lon iza t ion w i t h its accompanying r a c i a l i z i n g practices. Enormous ly h igh death rates, w h i c h carr ied personal sorrow and f a m i l y and communi ty desolation, were further punctuated b y the environmental changes that had begun by the early 20th century, that i s , " increas ing restrictions to land and resources" as w e l l as " intensifying interventions," such as residential schools , into the l ives o f A b o r i g i n a l p e o p l e s 4 9 ( K e l m , 1998, p . 18). Res ident ia l schools and boarding homes have been the most often c i ted cause o f the mental health concerns o f A b o r i g i n a l people. A l t h o u g h residential s choo l ing was not un i formly negative for a l l p e o p l e , 5 0 its overa l l impact has been devas ta t ing . 5 1 T h i s is a history o f loss o f 1) attachment to communi ty and the relationships o f trust bu i l t there; 2) cul tural values and norms w h i c h p rov ided a sense o f cul tural identi ty i n c l u d i n g language and spiri tuali ty; 3) health and i n some cases, l i fe ; 4) l i fe sk i l l s usua l ly taught b y parents, elders, and other c o m m u n i t y members , for example , parenting s k i l l s ; and 5) self- identi ty/worth, for 4 9 The high mortality rates amongst Aboriginal people relative to non-Aboriginal people continued, 5 0 In her research with Carrier people of north central BC, Fiske (1996) carefully documents how women advanced their social, economic, and political roles within and outside their communities using some of the skills and knowledge acquired in residential schools. In spite of harsh treatment, these women were paradoxically able to build structures of resistance to a system that unintentionally provided them with the tools to do so. She states: "Women (and men) selectively utilized novel skills and knowledge beneficial to themselves. And, in doing so, they effectively subverted the missionaries' intentions by broadening their economic strategies and by developing sophisticated political responses, which to a large measure were spearheaded by a schooled female leadership" (p. 181). 5 1 The intergenerational effects of residential schools and boarding homes are now well known and understood (Chrisjohn & Young, 1997; Fournier & Grey, 1997; Kelm, 1998; Royal Commission on Aboriginal Peoples, 1995, 1996b; Waldram et al., 1995; Waldram, 1997; Wade, 1995; Warry, 1998). However, I thank members of the Aboriginal Mental Health 'Best Practices' Working Group, BC for drawing attention to the fact that this "trauma" has not had the same consequences for all Aboriginal people. In fact, many people have done extremely well. It is for the benefit of those who have not fared so well that I draw attention to this important issue. In recognition of the intergenerational effects of residential schooling, the Aboriginal Healing Foundation was established in 1998 by the Federal government. It has been mandated to allocate $350 million towards addressing the legacy of abuse inflicted on Aboriginal students in residential schools. 36 example , be l i e f i n one 's creative abi l i t ies . M o r a l discourses o f A b o r i g i n a l inferiori ty reflect a deeply engrained assumption o f Euro -Canad ian superiori ty and paternalist benevolence (Furniss , 1999) that has its roots i n early A b o r i g i n a l - n o n - A b o r i g i n a l relations. A s a p r inc ipa l strategy o f Indian socia l po l i cy k n o w n as "aggressive c i v i l i z a t i o n " (Wade , 1995), the attitude o f Wes te rn superiori ty was inculcated into the minds o f A b o r i g i n a l ch i ld ren w i t h i n the residential s choo l system. The bu i ld ing o f residential schools often took the place o f b u i l d i n g day schools to ensure that ch i ldren w o u l d not be "contaminated" by their A b o r i g i n a l parents, f ami ly , or communi ty (Fleras & E l l i o t t , 1992): "Predica ted o n the no t ion that the F i rs t Na t ions were , by nature, unclean and diseased, residential schoo l ing was advocated as a means to "save" A b o r i g i n a l ch i ldren from the insalubrious influences o f home l ife o n reserves" ( K e l m , 1998, p. 57). The paint ing o f A b o r i g i n a l parents as " incompetent" p rov ided the m o r a l jus t i f i ca t ion for r emov ing ch i ld ren f rom their homes ( K e l m ) and extended famil ies , usua l ly for 10 months o f the year, f rom the age o f 5 or 6 years unt i l they were o l d enough to leave the insti tution ( M u s s e l l , N i c h o l s & A d l e r , 1991) . 5 3 A l t h o u g h authorities cont inued to espouse the be l i e f that residential school ing was essential to the su rv iva l o f A b o r i g i n a l peoples, mortal i ty and morb id i ty rates were a la rmingly h igh . A c c o r d i n g to K e l m (1998), the goal o f residential schoo l ing was to " re - fo rm" A b o r i g i n a l bodies , and this they d i d . B u t the results were not the strong robust bodies o f the schools propaganda, 5 2 The first residential school in BC opened in 1861 and the same school was the last to close in 1984 (Ward, 2001). 5 3 According to Haig-Brown (1988), students were sent home for a few reasons - when they became ill, some who ran away were allowed to stay home and, others left school when they reached the final grade, which for many years, was grade eight. Later, in the 1950s, "when high school was included, some people graduated" (p. 115). 37 w e l l t rained for agr icul tural and domest ic labour, but weakened ones , 5 4 w h i c h , through no fault o f their o w n , brought disease and death to their communit ies , (p. 57) M o r b i d i t y and mor ta l i ty rates were attenuated by worsen ing condi t ions i n the schools brought o n by decreasing funding. P o o r l y venti lated bui ld ings and ove rc rowding , i n addi t ion to the fact that ch i ld ren were sometimes inadequately fed, ove rworked , and abused, left the residents more vulnerable to communicab le diseases such as tuberculosis , measles, and inf luenza as w e l l as to the compl ica t ions o f less serious i l lness ( K e l m , 1998). Often ch i ld ren were discharged home to die, o n l y to infect their f ami ly and commun i ty members; others were returned to schoo l i l l because there was no other place they c o u l d receive care. Regardless o f the interventions by a few off ic ia ls , mandatory enrol lment and these problems cont inued. W h i l e m a n y A b o r i g i n a l parents intervened o n beha l f o f their chi ldren , some were actual ly j a i l e d for contravening the legis la t ion that mandated government school ing for their ch i ld ren . The co lon iza t ion practice o f us ing residential s choo l ing as a means o f producing cul tural conformity is a g loba l phenomenon and one w h i c h has been pract iced for some t ime. Regardless o f the fact that soc ia l cont ro l is widespread (and an element o f a l l education), i t can be par t icular ly destructive i n the context o f co lon ia l relations ( K e l m , 1998). A c c o r d i n g to the B r a z i l i a n educator Pa u lo Fre i re (1970/1997), the int rusion into and blatant disregard for the cul tura l context o f another group (the "oppressed") through educat ion o f this k i n d serves 5 4 As early as 1907, Dr. Peter Henderson Bryce, soon to be the medical officer for the Department of Indian Affairs, found that on the prairies, "at least one-quarter of the students enrolled in residential schools, died while on school rolls, or shortly thereafter, from diseases, predominantly, tuberculosis, which they contracted while in the institutions" (Kelm, 1998, p. 64). At one school in British Columbia, Bryce found that 34% of the students admitted to the school since 1892, were dead by 1909 - a "scandalous procession of Indian children to school and on to the cemetery" (p. 64). 38 to create a barrier to the creat ivi ty o f the invaded by l i m i t i n g their expression, w i t h disastrous soc ia l consequences. A l t h o u g h there are no exact figures, it is estimated by A b o r i g i n a l peoples that up to one m i l l i o n ch i ld ren attended residential schools i n their over 100 year history, i nc lud ing about one h a l f o f the schoo l aged ch i ld ren i n B C (Wade, 1995). In some famil ies , as many as f ive generations o f ch i ld ren attended. D a i l y forms o f dehumanizat ion, i so la t ion , and abuse have been w e l l documented i n many o f the residential schools (Chr i s john & Y o u n g , 1997; Wade) . M a n y parents lost confidence i n their parenting practices and experience[d] feelings o f ineffectiveness, and those w h o were schooled i n the residential school system themselves learned their parenting sk i l l s w i t h i n insti tutional environments, w h i c h were sometimes abusive (Brant, 1993). T h i s latter phenomenon continues to haunt many A b o r i g i n a l communi t ies today i n the fo rm o f f ami ly v io lence and other types o f abuse , 5 5 i nc lud ing lateral v i o l e n c e . 5 6 A l t h o u g h many ind iv idua l s reintegrated into their communi t ies f o l l o w i n g their school ing per iod, this was not possible for everyone. A c c o r d i n g to K e l m (1998), for some graduates, integration was not possible and they were described as be ing "cross-cul tural Of note here, Ojibwa elders have spoken about the precontact notion of child abuse as ob-je-e-tim "just not done" (Royal Commission on Aboriginal Peoples, 1995). Many First Nations children have left the reserves for the streets of urban centres in response to the abuse in their homes only to find more abuse and hardship. In fact, 37% of the people using needle exchange and 65% of the children in the sextrade in Vancouver's Downtown Eastside are Aboriginal (Vancouver's Downtown Eastside, 1999). Suicide is often the result. 5 6 This is violence inflicted from within a particular group. As an illustration, I cite the following example - the headline of a BC paper reads, "Rid us of this brute: Members of a BC band are living in fear of a chief they say has operated a reign of terror over three decades" (Fournier, 1999). This article describes the effort of a reserve community in BC, "to get rid of their Chief who has been re-elected numerous times since the late 1960s, "despite convictions for sexual assault in 1972, 1990, 1998 and several attempts to remove him." Several members of the community accuse the Chief of nepotism, threats of violence, sexual assault and reprisals for those who oppose him, for example, withholding education and social assistance funds. Lateral violence is a well-documented consequence of colonization (Duran & Duran, 1995, 2000; Fanon, 1967). 39 zombies , empty bodies m o v i n g across the landscape o f w h i c h they cannot quite be a part" (p. 79). In i t ia l ly , w h e n returning home, many o f the residential schoo l graduates learned tradit ional knowledge and sk i l l s through fami ly members. H o w e v e r , a few generations later, fewer ind iv idua l s had these opportunit ies because o f the dec l ine o f t radi t ional economies . A l s o , s m a l l numbers o f A b o r i g i n a l peoples were able to f ind employment o n reserve and i f they d i d , they tended to f ind seasonal w o r k " w h i c h i n v o l v e d phys ica l ly demanding labour and/or poor p a y " 5 7 ( M u s s e l l et a l . , 1993, p . 14). T h i s reali ty has l e d to the h i g h rates o f unemployment , poverty, and despair for young people i n many A b o r i g i n a l communi t ies today: O l d methods o f cop ing , the o l d phi losophies and re l ig ions , w h i c h taught resi l ience, su rv iva l and a sense o f be ing at one w i t h nature, have been denigrated and destroyed b y dominant culture and discarded by many abor ig ina l people. (Brant, 1993, p . 62) A l t h o u g h many gains have been made as a result o f reconnect ion to A b o r i g i n a l traditions " such as sweat lodges, sweet grass ceremonies and the establishment o f departments o f A b o r i g i n a l studies at var ious universi t ies where young people rediscover the o l d w a y s " (Brant, 1993, p. 62), the intergenerational effects o f residential s choo l ing continue to be experienced i n A b o r i g i n a l communi t i es and have been compounded by l i fe o n reserve for many. 5 7 Of Canada's approximately 2284 reserves, which vary in number over time according to the policy of the federal government (Frideres, 1998), 1600 are located in BC. However, "the paradox of aboriginal life in British Columbia, as in many other parts of Canada, is that the reserve is home, but on reserve, there is little employment opportunity" (Elliott & Foster, 1995). This reality forces many Aboriginal people to live and work off reserve. 40 T h e cul tural hegemony imposed by the c o l o n i z i n g force was pervasive. Indoctr inat ion o f dominant values, language , 5 8 and culture were central to the educat ion o f A b o r i g i n a l chi ldren , i nc lud ing health education, w h i c h set out to supplant t radi t ional A b o r i g i n a l approaches to health and heal ing. A s K e l m (1998) states, "Just as 'heal thy ' and 'Ch r i s t i an ' were equated, so were ' t radi t ional ' and 'd iseased '" (p. 62). A l t h o u g h many o f the d iscr iminatory sections o f the Indian Act were eventual ly repealed, i t was "not i n t ime to stay the in ternal izat ion o f many European patriarchal notions and pract ices" (Stevenson, 1999, p . 74). Nega t ive identities created i n the past endure today as engrained attitudes o f Western superiori ty cont inue to foster the tensions and disjunctures w i t h i n menta l health insti tutional settings and pol ic ies . In the next two sections, I shift the focus o f the d iscuss ion to the current context o f A b o r i g i n a l menta l heal th and hea l ing . I begin by d iscuss ing the issue o f self-government and heal ing. Several authors assert that self-government has the potential to break the cycle o f poverty, v io lence , and the many soc ia l i l l s experienced by A b o r i g i n a l peoples and as such, "s ignif icant ly alter the web o f causation that n o w results i n the extensive burden o f i l lness o f A b o r i g i n a l people" ( O ' N e i l et a l . , 1999, p. 151). I then go on to discuss the impact o f mental health reform w h i c h provides the context i n w h i c h mental heal th care continues to be provided. In several ways , mental health reform provides another l eve l o f challenge to self-governing arrangements. 5 8 Children were often severely punished for using their Aboriginal language (Chrisjohn & Young, 1997; Fournier & Grey, 1997; Haig-Brown, 1988; Wade, 1995). For example, at the Annual Native Mental Health Conference in London Ontario in 2002, one female participant recounted being punched in the face by the school master when she was heard using her Aboriginal language on the school playground at recess. 41 Current Context: Self-Government and Healing Since the early 1970s, there has been increased pressure b y A b o r i g i n a l organizations for the right o f A b o r i g i n a l peoples to govern themselves (Armi tage , 1995). F o r many A b o r i g i n a l peoples i n Canada , consti tutional recogni t ion o f A b o r i g i n a l rights as understood from an A b o r i g i n a l perspective is fundamental to health improvement . Because the causal mechanisms that exp l a in i l l health extend into " a l l aspects o f the soc ia l , cul tura l and po l i t i ca l l ives o f the A b o r i g i n a l peoples ," it is diff icul t to establish a direct causal l i n k between self-government and health. H o w e v e r , it is expected that self-government w o u l d result i n improved health for A b o r i g i n a l peoples i n several ways . It is expected to (1) improve economic status through the resolut ion o f lands c la ims and consequent resources i n the form o f cash or land, as w e l l as through increased employment opportunit ies and i m p r o v e d wages; and (2) improve self-esteem and empowerment . It is be l i eved that b y strengthening communi ty par t ic ipat ion us ing empowerment approaches and g round ing self-government i n "tradit ional soc ia l values o f A b o r i g i n a l medic ine teachings," p o l i t i c a l , cul tura l , and health development w i l l be further facili tated ( O ' N e i l et a l . , 1999, p. 150). In essence, self-government w i l l improve the health o f A b o r i g i n a l peoples by addressing the poverty, disadvantage, and consequent hopelessness that n o w cause an extensive burden o f i l lness i n A b o r i g i n a l communi t ies ( O ' N e i l et al .) . Hea l th transfer arrangements , 5 9 o f f ic ia l ly launched by H e a l t h Canada i n 1986, represent a c r i t i ca l step towards self-government ( O ' N e i l et a l . , 1999; Read , 1995). A l t h o u g h 5 9 Under 'health transfers', a process has been underway for transferring certain responsibilities for managing and delivering health services, especially community health and primary health care services, from Health Canada to Aboriginal communities. As of 2001, 82% of eligible First Nations and Inuit Communities have, or were in the process of, transferring responsibility, with 46% having signed transfer agreements (First Nations Inuit Health Branch ,2001; Romanow, 2002, p. 212 ). 42 transfer o f heal th and heal th care responsibi l i t ies to A b o r i g i n a l communi t i e s is considered an important objective, there are several concerns: (1) some fear i t w i l l result i n federal government w i thd rawa l f rom its h is tor ica l commitment to protect the heal th o f A b o r i g i n a l peoples ( W a l d r a m et a l . , 1995); (2) others cr i t ic ize the p o l i c y for f a i l i n g to consider emerging needs and consequent costs ( O ' N e i l et a l . , 1999); (3) some speculate that the transfer arrangements m a y be part o f the government 's p lan to off load programs and conta in costs rather than provide support for ini t iat ives focused o n meet ing A b o r i g i n a l commun i ty needs (Culhane Speck, 1989; Gregory , R u s s e l l , H u r d , Tyance , & S loan , 1992; O ' N e i l et a l . , 1999); (4) newly imposed ce i l ings o n spend ing 6 0 preclude arrangements i n w h i c h program enrichment can occur and thus, the medica l i za t ion o f federally de l ivered services continues without the opt ion for n e w models o f health and soc ia l p rog ramming w h i c h can address the broader socia l determinants o f heal th (Gregory et a l . ; O ' N e i l et a l . ) ; and (5) the continued dominance o f the m e d i c a l m o d e l as an organ iz ing approach to service has resulted i n 'Hea l th Transfer ' arrangements w h i c h have accompl i shed li t t le i n the w a y o f addressing the relations o f power over A b o r i g i n a l people (Gregory et a l . ) . 6 1 M o s t o f the c o m m u n i t y health development ini t iat ives i n A b o r i g i n a l communi t ies have occurred under the auspices o f the 1986 Transfer Initiative o f the M e d i c a l Services B r a n c h o f H e a l t h and Wel fa re Canada ( n o w Firs t Na t ions and Inuit H e a l t h Services Branch) . A l t h o u g h there have been numerous pre-transfer and transfer projects o f this k i n d since 1991, 6 0 A newly imposed ceiling on spending to First Nations and Inuit Health Services initiated in 1995/96 has limited the capacity for growth in the budget. In addition, although the Romanow Commission Report on the Future of Health Care in Canada (2002) makes several noteworthy recommendations to approaching Aboriginal health issues, including new funding partnership arrangements, it failed to recommend increased funding for Aboriginal health. 6 1 Gregory et al. (1992) argue that by definition the medical model maintains relations of power over Aboriginal peoples. 43 again, these agreements afford the A b o r i g i n a l communi ty o n l y administrat ive control as opposed to absolute control over the p lanning, implementat ion, and des ign o f such programs ( O ' N e i l & Pos t l , 1994; O ' N e i l et a l . , 1999). L i t t l e real empowerment o f A b o r i g i n a l communi t ies m a y be occur r ing due to inconsistencies i n transfer arrangements (Fleras & El l io t t , 1992), "the unclear relat ionship w i t h self-government, the l ack o f recogni t ion o f treaty rights to health, the l ack o f legis lat ive authority to enforce pub l i c health laws, and, the need for program enrichment to meet new needs" ( O ' N e i l & Pos t l , p . 78). In addit ion, these constraints intersect w i t h po l i t i ca l economic interests and the preva i l ing pla t form on A b o r i g i n a l heal th to shape h o w med ica l services evolve . Regardless o f their overa l l improved health status, A b o r i g i n a l peoples continue to struggle to address the persistent mental health inequities s temming from wider soc ioeconomic and po l i t i c a l issues. Nevertheless, l oca l l y cont ro l led health services have resulted i n pos i t ive changes i n some communi t ies and transfer arrangements continue. Fo r example, i n a study o f the results o f p r imary care under band control i n M o n t r e a l Lake , Saskatchewan, M o o r e , Forbes , and Henderson (1990) reported thirteen direct or indirect posi t ive healthy outcomes. A b o r i g i n a l peoples are seeking responsibi l i ty for adminis ter ing and cont ro l l ing their o w n health programs w i t h the be l i e f that "true c o m m u n i t y heal ing and w e l l - b e i n g can be found o n l y through self-government and self-determination" ( O ' N e i l et a l . , 1999, p. 149). Importantly, health p o l i c y agendas w i l l be set by A b o r i g i n a l peoples. A s O ' N e i l et a l . assert 6 2 "People feel the reserve is safer; People feel better cared for; Confidentiality and trust of health care staff have been enhanced; Elders feel better cared for; Healthy changes in lifestyle were reported; Children were hospitalized less often; Less violence was reported in the community; There was less alcohol and more "dry" activities; Coordination with hospitals was better; More comprehensive services were provided; There were better emergency and acute care services; Earlier intervention in the disease cycle was reported, with projected lower hospitalization rates; and, Health center staff were perceived as role models for community health development" (Moore, Forbes, & Henderson, 1990, cited in O'Neil et al., 1999). 44 I f employment , self-esteem, and personal empowerment are improved , there w i l l be a d i m i n u t i o n i n the number o f injuries, suicides, and homic ides that plague communi t i e s today. A n d w i t h the control i m p l i c i t i n self-government, A b o r i g i n a l people w i l l assume roles n o w f i l l ed by n o n - A b o r i g i n a l people. T h e posi t ive impact o f this ro le m o d e l i n g o n young A b o r i g i n a l people w i l l d i m i n i s h a l coho l and drug dependency, v io l ence , and other socia l i l l s . (p. 151) T h e c o l o n i a l legacy w i t h respect to A b o r i g i n a l people is l ong ; i t is a legacy that i s w e l l entrenched, and its vestiges continue to be v i s ib le today. S o m e progress towards self-governance i s be ing made, however , control o f institutions and services has not been achieved i n many areas. A s A r m i t a g e (1999) asserts, " [ a l t h o u g h there has been an increase i n the number o f A b o r i g i n a l service-del ivery agencies, i t is naive to equate the creat ion and operation o f these agencies w i t h self-government" (p. 76). The f o l l o w i n g section on mental health reform provides a b r i e f o v e r v i e w o f some o f the obstacles fac ing A b o r i g i n a l peoples i n achieving recogni t ion o f A b o r i g i n a l i t y 6 3 w i t h i n mental health service de l ivery i n the context o f menta l heal th reform. A s one o f the most vulnerable populat ions i n Canada , the residents o f A b o r i g i n a l communi t i e s are part icularly sensitive to the consequences o f d o w n s i z i n g and other cost-cutt ing measures i n the health care system ( O ' N e i l et a l . , 1999, p. 148), i nc lud ing the threat i t poses to A b o r i g i n a l autonomy. 6 3 In the dissertation, I use the concept "Aboriginality" in the same way as McConnell and Depew (1999) to refer to "the complex social and cultural diversity represented by contemporary Aboriginal people in Canada (p. 353) rather than a superficial and abstract view of what is entailed in being Aboriginal. According to McConnell and Depew this kind superficial view often amounts "to little more than attributes and attitudes th non-Aboriginal people associate with, and find palatable in, the idea of Aboriginality. In fact, Aboriginality i often being ignored" (p. 368). 45 Mental Health Reform: Current Patterns of Tensions and Disjunctures The current context o f mental health reform also informs the analysis o f the nature o f the tensions and disjunctures i n this study. Heal th reform is a g loba l phenomenon, affecting the l ives o f people across the globe, but certainly not equal ly (Anderson , 2000 , p . 223) . Discourses o f scarcity and eff iciency over the past several decades have l ed to cost containment i n countries such as Canada, and a massive restructuring o f the health care system (Anderson , 2000; Burgess , 1996; Evans , 1992; Storch, 1996; V a r c o e and Rodney , 2002) . In keeping w i t h this movement , the 1998 M e n t a l Hea l th P lan , Revitalizing and Rebalancing British Columbia's Mental Health System ( R R B C ) , was produced as a too l o f overa l l mental health reform w i t h the goal to "support the development o f comprehensive, integrated regional menta l health care systems for B r i t i s h C o l u m b i a n s w i t h the most serious and d i sab l ing menta l i l lness , their famil ies and the communi t ies where they l i v e " (p. i ) . R R B C was also intended to b u i l d o n the continued redevelopment and decentral izat ion o f R i v e r v i e w H o s p i t a l , a tertiary psychiatr ic care faci l i ty, into communi ty-based spec ia l ized care faci l i t ies . T h i s 1998 M e n t a l Hea l th P l a n ( R R B C ) is consistent w i t h the recommendat ions o f the nat ional d iscuss ion paper, Best Practices in Mental Health Reform (Cochrane, D u r b i n , G o e r i n g , 1997), prepared for the 'Federa l /P rov inc ia l / Terr i tor ia l A d v i s o r y N e t w o r k o n M e n t a l H e a l t h ' , w h i c h represents the most current information about effective, evidence-based services and service models i n the N o r t h A m e r i c a n experience ( R R B C , 1998, p. i i ) . T h i s document has been h i g h l y influential i n setting the themes o f reform, i nc lud ing assertive case management, consumer involvement , cr is is response/emergency services, f ami ly support and involvement , hous ing , inpatient/outpatient services, psychosoc ia l rehabil i tat ion, 46 and, the protect ion o f h u m a n freedoms and rights. In addi t ion, a l though each province is preparing a response to meet mental health need relative to their o w n circumstances, mental heal th p o l i c y across a l l ju r i sd ic t ions i n Canada is in formed b y H e a l t h and Wel fa re Canada ' s health p romot ion and prevent ion framework (Epp , 1986, 1988). H o w e v e r , the central d r iv ing force o f mental health reform over the past several decades has been deinst i tut ionalizat ion. T h i s movement, w h i c h began i n the 1950s, escalated i n the 1960s, and between the 1960s and 1976, the number o f beds i n the menta l hospitals decreased considerably " f r o m 47,333 to 15,011" (p. 372). H o w e v e r , at the same t ime, there was an increase i n communi ty-based alternatives, i nc lud ing general hospi ta l beds, " f r o m 844 to 5836," and a substantial increase i n in-patient hospital izat ions (p. 372). F r o m the late 1960s unt i l the early 1980s, "mental disorder rose f rom the fifth most c o m m o n to the leading cause o f in-patient treatment i n general hospitals" (B l i shen , 1991, pp. 36-38, c i ted i n D i c k i n s o n , 2002 , p . 372). W h i l e some bel ieve that the n e w popular i ty o f the " b i o l o g i c a l cause" theory o f mental i l lness coupled w i t h the n e w psychotropic medic ines was responsible for this growth i n general hospi ta l psychiatry, others see i t as another f o r m o f soc ia l cont ro l prompted by economics and pol i t ics , namely soaring costs and the need for constraint ( D i c k i n s o n , 2002 , p . 374). In reality, it was probably mot iva ted by both. Po l i c i e s are neither neutral nor mere instruments o f eff iciency and effectiveness, but rather a part o f the apparatus o f po l i t i cs , ideologies , and power (Shore and W r i g h t , 1997). T o date, the majori ty o f mental health costs are associated w i t h general hospital-based treatments, and the deinst i tut ional izat ion movement is considered a failure ( D i c k i n s o n , 2002 ; Tra inor , C h u r c h , Pape, Pomeroy, R e v i l l , Teft, et a l . , 1992). A l t h o u g h the creat ion o f general hospi ta l in-patient 47 beds, i n its early phases, was intended as a movement towards c o m m u n i t y psychiatry, the movement to establish communi ty-based services and resources has fa i led miserably. O n e o f the most serious consequences o f this p lan has been the g r o w i n g numbers o f people l i v i n g i n the streets o f urban centers: homeless or near-homeless persons w i t h mental i l lness are a ubiqui tous feature o f the Canad ian landscape (Baxter , 1991; D i c k i n s o n , 2002) . In addi t ion many ind iv idua l s have become caught up i n the c r i m i n a l jus t i ce sy s t em 6 4 (p. 383). " N a n c y H a l l (the former menta l health advocate i n B C ) estimates that 3 2 % o f the inmates i n correct ional faci l i t ies have some k i n d o f menta l disorder" ( D i c k i n s o n , p . 383) . Unfortunately, on ly too often the j a i l becomes a "default pos i t ion" for those w h o cannot access the mental health system ( H a l l , 2001) . A s noted previously , a disproportionate number o f A b o r i g i n a l peoples are represented i n Canada ' s correct ional faci l i t ies , a fact associated w i t h several factors i nc lud ing d i s c r i m i n a t i o n 6 5 and oppression ( W a l d r a m , 1997). M a n y o f these ind iv idua ls struggle w i t h mental health issues associated w i t h histories o f v io lence , poverty, unemployment , despair, and hopelessness (anomie). C r i m e i n the A b o r i g i n a l communi ty is also often l i n k e d to a l coho l and other substance abuse and marg ina l i za t ion o f A b o r i g i n a l people w i t h an a lcoho l and/or other substance abuse issue and/or menta l health p rob lem is a l l the more l i k e l y (Furniss , 1999; W a l d r a m , 1997). In response to the fai lure o f deinst i tut ionalizat ion, p o l i c y makers have embraced decentralization and reg iona l iza t ion w i t h the goal o f i m p r o v i n g menta l heal th program 6 4 Dickinson refers to this as trans institutionalization, or movement from one system into the other (p. JSJ). 6 5 For example, critical analysts believe that Aboriginal people are more likely to attract police [and social] attention than non-Aboriginals (Waldram, 1997). 48 planning and development.66 In essence, it is expected that (1) mental health service delivery needs will be location-specific and thus meet local need, and (2) decentralization and regionalization wil l facilitate the opportunity to mobilize and reallocate resources in the communities of most need (Dickinson, 2002, p.3 83). Dickinson reports that on the one hand, some feel this will mobilize "democratic" [italics mine] decision making into new areas of community life (p. 383). However, others express concern over the divisive nature of this kind of local decision-making regarding resource allocation that may result in an politicization of health care at the local level. 6 7 The composition of regional health authorities has become increasingly important because of the number of vested interests in mental health with diverse visions, and therefore, the nature of the membership of regional planning and administrative bodies that is emerging across the country needs to be considered i f democratization is to be achieved (Dickinson). In relation to Aboriginal peoples in BC, the regionalization process creates challenges in a couple of ways: (1) another level of jurisdictional confusion is created - "downsizing and restructuring of health services to a population that relies on services from different 68 jurisdictions encourages attempts at 'cost shifting'" (O'Neil et al., 1999, p. 149); and (2) with devolution, there is a decentralization of Aboriginal power. In December 2001, the new BC Liberal government introduced its health care restructuring plan, A New Era in Patient 6 6 In the 1980s, in the health care system more broadly, increasingly declining federal transfer payments coupled with escalating health costs forced provincial governments to begin a dramatic overhaul of their provincial health care systems (O'Neil et al., 1999). 6 7 The assumption embedded in idea of a democratic decision making is that all people have equal opportunity to have their voice heard and responded to - however, for those who are oppressed and marginalized this does not necessarily hold true (Sherwin, 1992; Young, 1990). 6 8 According to O'Neil et al. (1999), where provincial governments have cut back, the federal government has been pressured to fdl in. A recent two year cap on provincial funding likely means that Aboriginal health needs are not going to be met by any level of government in BC (Vancouver Coastal Health Authority, personal communication, October 4, 2003) given that federal funding also operates with funding restrictions. 49 Centered Care, w h i c h created f ive regional health authorities out o f the previous 52 different health authorities ( B C , 2001) . T h e overa l l goal o f this p l an has been to " improve efficiency, strengthen accountabi l i ty and a l l o w better p lanning and service coord ina t ion . . . .and to create a sustainable, affordable pub l i c health system" (p. 1). A s part o f the devo lu t ion process, the A b o r i g i n a l Hea l th D i v i s i o n o f the M i n i s t r y o f Hea l th was e l imina ted a long w i t h several other smaller A b o r i g i n a l H e a l t h agencies. Instead o f a central A b o r i g i n a l health body at the leve l o f the M i n i s t r y o f Hea l th , each o f the f ive regional health authorities has hi red an A b o r i g i n a l health i nd iv idua l w i t h va ry ing pos i t ion titles across the regions i n c l u d i n g : director, manager, contract coordinator, strategy coordinator, and l i a i son person. In re la t ion to the mental health complex , nine A b o r i g i n a l mental health l i a i son workers were h i red across the five regions. T o date, a l though the posi t ions are i n place, there has not been designated resources to support the development o f A b o r i g i n a l mental health programs ( P o l i c y Participants, 19, 20). In addi t ion, the A b o r i g i n a l M e n t a l Hea l th Best Practices W o r k i n g G r o u p , 6 9 w i t h a membership o f A b o r i g i n a l and n o n - A b o r i g i n a l peoples across B C , was e l iminated by the M i n i s t r y at this t ime ( w i t h i n one year post election). T h i s group had comple ted a discuss ion paper, Aboriginal Mental Health: What Works Best ( M u s s e l l & S m y e , 2001) , for dis t r ibut ion among and input o f A b o r i g i n a l peoples across the province to assist w i t h the development o f 6 9 The Aboriginal Mental Health Best Practices Working Group formed out of the Aboriginal Mental Health Advisory Committee which began meeting in July, 1999. The group formed in response to concerns that mental health service delivery, including the field of community psychiatry, did not adequately - or appropriately -deal with the needs of Aboriginal people. The membership of the Committee/ Working Group reflects the broad range of expertise already available among BC's Aboriginal community, as well representing the full range of mental health professionals. The following key areas for its work include the need to: i) review, assess and develop Aboriginal perspectives on Best Practices in Mental Health and facilitate the development of a BC Aboriginal Mental Health Plan; ii) disseminate a plan specifically related to best practices in Aboriginal mental health to the health authorities in the planning of mental health reform; iii) conduct research into Aboriginal best practices and effective service and program models; and, iv) examine alternative models of service delivery that are accessible, culturally appropriate/safe and accountable for Aboriginal people. Funding was provided by Adult Mental Health Services, Ministry of Health, administered through Mental Health Evaluation and Community Consultation Unit (Mheccu), Department of Psychiatry, UBC until September 2001 (Mental Health Evaluation and Community Consultation Unit, 2001). 50 a p rov inc i a l A b o r i g i n a l M e n t a l H e a l t h P l an . A l t h o u g h this process was halted, the paper is available o n the M i n i s t r y o f Hea l th , A d u l t M e n t a l Hea l th D i v i s i o n under the M e n t a l Hea l th Eva lua t ion and C o m m u n i t y Consu l ta t ion (Mheccu) website. T h i s phasing out o f separate A b o r i g i n a l inst i tut ional structures i n B C impl ies an under ly ing ass imila t ionis t ethos (Fleras & E l l io t t , 1992, p . 54 ; Fleras , 2000) and a l ack o f support for A b o r i g i n a l autonomy and governance i n the B C L i b e r a l government ' s Indian po l i cy . A l t h o u g h "c loser to h o m e " approaches create an opportunity for A b o r i g i n a l communi t ies , both urban and rural , to l ia ise w i t h one board, the effectiveness o f this process varies f rom region to reg ion dependent o n several factors i n c l u d i n g the p r o x i m i t y o f the A b o r i g i n a l c o m m u n i t y to the major service center i n the region, the recept ivi ty o f the health authorities to A b o r i g i n a l health issues, and, i n the case o f Fi rs t Na t ions , their preference for deal ing w i t h the federal government ( O ' N e i l et a l . , 1999, p. 148). A s O ' N e i l et a l . also note, regional health authorities sometimes exclude Firs t Na t ions f rom consul tat ion because they are seen as a federal responsibi l i ty . A l s o , notably, al though the shift to m o v e resources f rom hospital to communi ty-based ini t ia t ives i n mental health w i l l l i k e l y benefit some people, it is un l ike ly F i rs t Na t i ons and Inuit communi t ies w o u l d benefit because o f the ju r i sd ic t iona l issue, (i.e., c o m m u n i t y services are considered a federal responsibi l i ty) . Here , the lack o f attention to A b o r i g i n a l i t y precludes a commitment to tripartite arrangements between federal, provinc ia l / reg ional , and A b o r i g i n a l bodies and again, respect for A b o r i g i n a l autonomous dec i s ion-making i n this matter. 7 01 consider provincial and regional governance bodies in this way because in BC, the province remains the policy making body and the region allocates resources in response to the health priorities the regions sets. For example, the regional body is mandated by the province to address Aboriginal mental health, however, the regions choose how they prioritize it alongside other important health issues (Policy Participant, 19). 51 In addi t ion to these issues, as noted i n Chapter One , current menta l health reform remains attached to b i o m e d i c a l traditions, i n particular, psychiatry. N o t surpris ingly, the target popula t ion o f re form is those persons w i t h serious and persistent menta l i l lness as defined w i t h i n a b i o m e d i c a l framework. A l t h o u g h this does not necessari ly preclude attention to the mental health issues o f some A b o r i g i n a l peoples, the assessment, diagnostic, treatment, and research modal i t ies associated w i t h b iomed ica l traditions are embedded i n Western thought and general ly r emain uninformed i n relat ion to the beliefs , values, and histories o f A b o r i g i n a l peoples (Duran & Duran , 1995, 2000; M c C o r m i c k , 1996, 1997 ,1998 ; M u s s e l l et a l . , 1993). F o r example , D u r a n and D u r a n (2000) comment o n the damage that has been done to some N a t i v e A m e r i c a n s as a consequence o f us ing assessment tools that do not fit w i t h A b o r i g i n a l perspectives/ w o r l d v i e w s - an example o f what they see as "inst i tut ional r a c i s m " (p. 93) . In re la t ion to treatment, they note that al though there are isolated instances o f success i n treatment, generally, programs addressing a lcoho l i sm, chemica l dependency, and h igh rates o f suic ide "appear impotent" (p. 90). The emphasis o n treatment approaches w i t h i n the mental health system leaves few resources for developing innovat ive approaches to prevention o f a poorer mental heal th status ( O ' N e i l et a l . , 1999, p. 147). In re la t ion to research, D u r a n and D u r a n (2000) assert that " s o c i a l scient i f ic invest igat ion into menta l health deproblematizes the material his tory o f sc ience . . . the object if icat ion o f N a t i v e A m e r i c a n psycholog ica l problems deprives them o f their material history and hence o f a c ruc ia l aspect o f their truth" (p. 96). Instead, a methodology o f psycholog ica l research needs to be broadened and made more relevant i n terms o f addressing the k inds o f c o m p l e x soc ia l problems facing A b o r i g i n a l peoples (p. 96) . D u r a n and Duran argue for a psycho logy that looks "deeper into the mul t id imens iona l nature o f mental health 52 for fresh perspectives and empower ing interventions instead o f p r i v i l e g i n g a universa l scientif ic discourse over the vo ice o f the subjects" (p. 97). In re la t ion to reform, al though the documents o f mental health reform address issues o f f ami ly and commun i ty , they do so f rom an understanding o f a "un ive r sa l " subject and an ind iv idua l i s t i c approach to heal th and heal ing. In addi t ion, the language o f Best Practices pr iv i leges "evidence-based"approaches steeped i n b i o m e d i c a l scient if ic traditions. N o n - W e s t e r n forms o f thought have not yet been legit imated. A s I discuss i n subsequent chapters, the ideo logy o f a ss imi la t ion w i t h its attendant ideologies o f paternal ism and ethnocentrism both shapes and is shaped by inst i tut ional structures, po l ic ies , and everyday practices. Concluding Comments T h e p r o v i s i o n o f health care to A b o r i g i n a l people has been shaped b y over a century o f internal c o l o n i a l 7 1 practices, po l ic ies , and pol i t i cs (Frideres & G a d a c z , 2 0 0 1 ; Pont ing , 1997; 2001 ; R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples , 1996b; W a l d r a m et a l . , 1995; W a r r y ; 1998). A s a consequence o f this history, the current mental heal th system is plagued by the same problems. Despi te a number o f important events over the past t w o decades , 7 2 w h i c h have d rawn attention to the mental health concerns o f A b o r i g i n a l people and the attendant 7 1 According to O'Neil (1986, 1989) internal colonialism is a 'Fourth World' situation in which a minority indigenous population is enveloped within a nation-state wherein powers and privileges are held by the colonizing majority that consciously or unconsciously subordinate the original inhabitants of the land. 7 2 Examples include the 1979 Berger commission report; the 1982 Special Committee report on Indian Self-Government; the Solvent Abuse initiative of Health Canada and INAC; establishment of a Steering Committee on Native Mental Health between 1990 and 1991 which developed a mental health framework document in consultation with First Nation and Inuit organizations and stakeholders; the recommendations of the Royal Commission on Aboriginal Peoples (1996b); and, the reconstitution of the Mental Health Working Group in 1998 with membership from the Assembly of First Nations (AFN), the Inuit Tapirisat Council (ITC), and Medical Services Branch (now FNIHB) "with its new mandate to provide leadership in planning and coordinating First Nations mental health services across Canada..." (Elias & Greyeyes, 1999, pp. 7-8). 53 systems o f health care, A b o r i g i n a l mental health is largely glossed over by the health authorities. A c c o r d i n g to the findings o f the Canada-wide environmenta l scan o f mental services i n Firs t Na t ions C o m m u n i t i e s conducted by E l i a s and Greyeyes (1999), the m a i n problems w i t h mental health services identif ied by A b o r i g i n a l people i n the P a c i f i c r eg ion were as fo l lows : M S B (now F N I H B ) is l eav ing the programs post health transfer too ea r ly , 7 4 setting programs up for failure; there are too few trained Firs t Na t ions therapists; there is a lack o f funds to transport therapists and clients; informat ion systems are not i n place; there is lack o f continuity between programs; cr is is response is poor; there is a l ack o f support for fami ly concerns, and a lack o f programs for v i c t ims and perpetrators o f sexual abuse; youth are underserved; and there is a predominance o f the med ica l m o d e l . O v e r a l l , they assert that there is a lack o f comprehensive programs. Instead, many people want a c o m m u n i t y mental health mode l w h i c h includes credible15 A b o r i g i n a l hea l ing methods (pp. 27-29) . E x a m i n i n g the s ignif icance o f previous co lon ia l relations is necessary to understanding the current soc ia l , po l i t i ca l , and economic condi t ions in f luenc ing A b o r i g i n a l mental health. In part icular, I have emphasized h o w c o l o n i z i n g attitudes cont inue to influence the w a y i n w h i c h mental health care is p rov ided to A b o r i g i n a l peoples. A s I argue later, current institutions and pol ic ies remain embedded i n i deo log ica l f rameworks that shape and are shaped by everyday practices w i t h i n the mental health system; dominant ideologies , mental health inst i tut ional po l ic ies and everyday practices intersect to shape the tensions or 7 3 These are similar to problems identified in other regions of Canada. 7 4 In some cases, before the respective community has the infrastructure necessary to administer (and hopefully develop) the program successfully. 7 5 Here "credible" refers to the validity and legitimacy in accordance with Aboriginal belief structures. 54 disjuncture between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental heal th system. The study presented here aims to explicate the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to menta l heal th and i l lness and the current mental health system by examin ing (1) the everyday practices that create barriers to access to mental health care for A b o r i g i n a l peoples, (i.e., the tensions and disjunctures); (2) the ideologies underpinning institutions, pol ic ies , and practices (i.e., w h y the tensions and disjunctures); and (3) the institutions and pol ic ies , (i.e., h o w insti tutions and pol ic ies support the embeddedness o f ideologies) . In the next chapter, I proceed w i t h the analysis o f the data by v i e w i n g the nature o f the tensions and disjunctures through a par t icular theoretical lens informed by pos tco lonia l perspectives. 55 C H A P T E R T H R E E L O C A T I N G T H E P R O B L E M IN A N H I S T O R I C A L C O N T E X T : T H E P O S T C O L O N I A L In the previous chapter, I outlined the significance of locating an analysis of Aboriginal mental health within the historical context of colonialism and, in particular, policy development, as well as today's internal colonial context. Postcolonial theoretical perspectives have obvious relevance to the objectives pursued in this dissertation. The research I present, therefore, is positioned within an emerging body of postcolonial scholarship. Given my own location within the field of Aboriginal mental health, I am also conscious of the need to engage critically with postcolonial theories that are congruent with the perspectives of Aboriginal scholars. Therefore, I begin by drawing on the work of Aboriginal people who have considered the relevance of postcolonialism to Aboriginal issues as a means of examining what some might consider an imposition of Eurocentric theoretical perspectives onto issues of central importance to Aboriginal peoples. Then, I examine the theoretical foundations of postcolonialism and its relevance as an analytic framework in this study. I go on to explore the ways in which the postcolonial provides an opportunity to uncover notions of "race," "racism," "culture," and conceptions of racialized "Other," and how identities have been created and are located within particular historical periods. Lastly, I introduce cultural safety from its New Zealand context to the Canadian policy arena. Cultural safety is discussed as an analytic lens for critiquing mental health policy, for unmasking the ways in which the current policies and practices unwittingly 7 6 As per Anderson (2002), I use a capital here to denote a particular constructed identity conferred on non-Western people "as inferior through the process of racialization and cultural essentialism" (p. 8). 56 perpetuate inequit ies i n heal th care and, as a consequence, the poorer health status o f A b o r i g i n a l people. Pos t co lon ia l i sm is one o f the cr i t ica l theories that provides another point o f scrutiny regarding knowledge development , taking us f rom the experiences o f those " w h o have suffered f rom the sentence o f history - subjugation, dominat ion , diaspora, displacement" (Bhabha , 1994, p. 172) to examine the soc ia l and his tor ical locatedness o f the product ion o f dominant discourses (Ande r son , 2002). In nurs ing we can use a pos tco lonia l lens to env i s ion h o w to meet nurs ing 's soc ia l mandate o f addressing the socia l aspects o f heal th and i l lness , situate i n d i v i d u a l experience w i t h i n the larger soc ia l context, g ive vo ice to subjugated knowledges and foster soc ia l jus t ice through an uncover ing o f soc ia l inequit ies. (Re imer K i r k h a m & A n d e r s o n , 2002, p. 9) Postcolonialism and Aboriginal Voice There is an increas ing number o f vo ices and forums "converg ing to fo rm a new perspective o n k n o w l e d g e " w i t h a commitment to " r ec l a iming indigenous vo ice and v i s i o n " (Battiste, 2000, p. x v i ) . M a n y o f those voices be long to Indigenous peoples who have l i v e d the legacy o f c o l o n i a l oppress ion and "cogni t ive i m p e r i a l i s m " (p. x v i ) . W h i l e posit ions vary o n pos tcolonia l theoretical perspectives, A b o r i g i n a l scholars w h o address issues o f relevance to A b o r i g i n a l peoples share concern over "the burden and contradictions o f co lon ia l his tory" (LaRocque , 1996, p. 14). F o r L a R o c q u e , a P la ins Cree M e t i s wri ter and professor, cr i t ica l inquir ies p rov ide an appropriate framework for examin ing the pervasive structural and psycholog ica l re lat ionship created by co lon iza t ion , and ul t imately reproduced i n the institutions, po l i c i e s , histories, and literatures o f dominant culture(s) (p. 11). 57 L a R o c q u e (1996) suggests a Canad ian scholarship w h i c h attends to "macroscop ic" examinat ion o f the dynamics o f oppression. In the context o f understanding the impact o f a protracted per iod o f co lon ia l i za t ion , she cal ls for scholarship w h i c h seeks to unmask the faces o f both co lon ize r and c o l o n i z e d w i t h i n academe and society at large. F r o m her perspective, there needs to be an increased awareness o f the " funct ion o f power and rac i sm and its impact o n A b o r i g i n a l peoples as w e l l as the signficance o f resistance" (p. 11). W h i l e commi t t ed to the p l ight o f a l l A b o r i g i n a l people, L a R o c q u e is par t icular ly concerned w i t h the w a y i n w h i c h oppress ion affects A b o r i g i n a l women . She wri tes: [t]he tentacles o f co lon iza t ion are not on ly extant today, but m a y also be m u l t i p l y i n g and enc i rc l ing N a t i v e peoples i n tight grips o f landlessness and marg ina l iza t ion , hence, o f anger, anomie, and v io lence , i n w h i c h w o m e n are the more obv ious v i c t ims , (p. 12) Therefore, scholars w h o engage i n this k i n d o f w o r k need to understand that "to study any k i n d o f v i o l a t i o n i s , ipso facto, to be engaged i n ethical matters." H o w w e do research and use that knowledge , can have serious ramifications for others, therefore, "[t]hese destructive attitudes, unabashed biases, pol ic ies , and v io lence that w e footnote cannot be mere intel lectual or scholar ly exercises" (LaRocque , 1996, p. 1 2 ) . Increasingly, A b o r i g i n a l scholars have engaged w i t h pos tco lonia l discourses as a way o f r ec l a iming and reposi t ioning indigenous voices , knowledges , and analyses (Battiste, 2000). Battiste, a M i ' k m a q professor, cal ls for an "Indigenous" scholarship w h i c h exposes neo-co lon ia l practices w i t h i n the educat ion setting. In her v i e w , " A b o r i g i n a l consciousness" cannot be mainta ined wi thout addressing the under ly ing assumptions o f modern society, i nc lud ing the educat ion system, i n tandem w i t h language r ev iva l , maintenance, and 58 development as part o f the project o f decoloniza t ion (p. 193). H o w e v e r , from her perspective, the "foundation"[ita[ics mine] for postcolonia l transformation is an Indigenous scholarship and research that "requires m o r a l dialogue w i t h and the par t ic ipat ion o f Indigenous communi t i e s" (p. x x ) . In addi t ion, Battiste cautions against the conf la t ion o f pos tcolonia l theory i n literature w i t h pos tco lonia l indigenous thought. In her v i e w , the latter is c ruc ia l to pushing beyond Eurocent r ic theory to transformative p r a x i s 7 7 - to address the mul t ip le forms o f "oppression, exploi ta t ion , ass imila t ion, coloniza t ion , r ac i sm, genderism, ageism and the many other strategies o f marg ina l iza t ion" (p. x x i ) . In this regard, Battiste cites the words o f M a r c Renaud , President o f the S o c i a l Sciences and Humani t ies Research C o u n c i l o f Canada, from his address to the academy, 7 8 i n w h i c h he asserted that the traditions o f the universi ty to "pub l i sh or pe r i sh" have been g loba l ly tested and that the n e w agenda for universi t ies w i l l need to be "go pub l i c or pe r i sh"" (p. x x ) . Battiste (2000) continues to question the place o f non- indigenous researchers i n the area o f Indigenous research. In relat ion to this issue, L a R o c q u e (1996) notes the way i n w h i c h A b o r i g i n a l scholars h ighl ight the usefulness o f pos tco lonia l discourses as means for chal lenging their n o n - A b o r i g i n a l colleagues to "re-evaluate their c o l o n i a l f rameworks o f interpretation, their conclus ions and portrayals, not to ment ion their tendencies o f exc lud ing from their footnotes scholars w h o are N a t i v e " (p. 13). T h i s phenomenon, coup led w i t h the 7 7 Here I have inserted the notion of praxis. In my view, Battiste is speaking of praxis-oriented inquiry in an emancipatory context in which research and knowledge development are focused on "generating useful or practical knowledge, interrupting patterns of power, participation in socially transformative processes toward such ideals as justice, equality, and freedom" (Thome, 1997, p. 126). In particular, she is foregrounding Indigenous knowledge. According to McCormick and Roussy (1997), [t]he notion of praxis acknowledges that research and practice are inevitably theory-laden and that these theories are influenced by individual's ideological commitments...Nurses who have a commitment to critical nursing praxis recognize the importance of theoretical perspectives that help expose the power and hierarchy embedded in the social world in which health decisions are made" (pp. 269, 279). 7 8 Sorokin Lecture, University of Saskatchewan, Saskatoon, February 4, 1999. 59 growing body o f literature o n "pos t -colonia l vo i ce s " (p. 13), is a ref lect ion o f the g loba l emergence o f indigenous vo ice and v i s i o n . In a somewhat different vo ice , L i n d a T u h i w a i S m i t h (1999), a M a o r i researcher and educator i n N e w Zealand, cal ls for the "deco lon iza t ion" o f research methods. In her book, Decolonizing Methodologies: Research and Indigenous Peoples, she unmasks the ways i n w h i c h research is l i n k e d w i t h European c o l o n i a l i s m and introduces the no t ion o f an Indigenous research agenda, not un l ike research programs w h i c h connect research to the " g o o d " o f society but different i n the inc lus ion o f key elements reflected i n words such as heal ing, decoloniza t ion , spir i tual and recovery. In her v i e w , the "pos t - co lon ia l " marks "an era o f new realities, new socia l identities, [and] new power a l l iances" w i t h w h i c h the Indigenous w o r l d has been confronted and has n o w chal lenged - it is a p lace not yet reached. A c c o r d i n g to T u h a w a i Smi th , to name the w o r l d as "pos t -co lon ia l " is to "name c o l o n i a l i s m as f inished business". She prefers instead to th ink o f this t ime as the pe r iod o f "deco lon iza t ion , " i n v o l v i n g a long-term process o f "bureaucratic, cul tural , l inguis t ic , and psycho log ica l d ives t ing o f c o l o n i a l power" (p. 98). In yet another vo ice , D u r a n and D u r a n (1995) introduce the no t ion o f a "pos tco lon ia l psychology ," a theoretical d iscuss ion o f problems and issues encountered i n N a t i v e A m e r i c a n communi t ies and the means o f addressing those issues that l eg i t imize N a t i v e knowledge and hea l ing practices. These authors underl ine the importance o f understanding intergenerational t rauma and internal ized oppression i n order to understand anomie and its attendant problems. W h i l e "difference" is acknowledged across w o r l d v i e w s - Wes tern and N a t i v e - the authors argue for a w o r l d i n w h i c h both can l i v e i n harmony, seeking something new between them. 60 W h i l e there are many other Indigenous voices w i t h i n pos tco lon ia l discourse, c o m m o n to these particular scholars is the commitment to a n e w scholarship or w a y o f being w h i c h challenges Eurocent r ic assumptions and value structures i n both academe and society at large. Importantly, a space is created for those knowledges that have been previous ly subjugated, and, for an Indigenous vision for m o v i n g forward. P o s t c o l o n i a l i s m provides a lens to examine the ways i n w h i c h the various racisms and r a c i a l i z i n g practices continue to operate to create barriers to the implement ing o f these v i s ions . R e c o g n i z i n g the contestations inherent i n the broad range o f theories contr ibut ing to pos tco lon ia l i sm, these are the applications o f pos tco lon ia l i sm that I turn to for their potential to chal lenge and disrupt the reproduction o f c o l o n i a l soc ia l formations ( M c C o n a g h y , 2000) . The Postcolonial: Theoretical Foundations In the last decade, pos tco lon ia l i sm has taken its place w i t h other theories as a major cr i t ica l discourse i n the humanit ies (Gandhi , 1998, p . v i i i ) as w e l l as i n var ious other disc ipl ines such as l i terary c r i t i c i sm. A c c o r d i n g to Quayson (2000), pos tco lon ia l i sm involves a studied engagement w i t h the experience o f c o l o n i a l i s m and its past and present effects, both at the loca l l eve l o f ex -co lon ia l societies as w e l l as at the l eve l o f more general g loba l developments thought to be the after-effects o f the empi re . . . [t]he term is as m u c h about condi t ions under i m p e r i a l i s m and c o l o n i a l i s m proper as about condi t ions c o m i n g after the h i s to r ica l end o f co lon i a l i sm , (p. 2) However , rather than s igni fy ing a temporal locat ion , M c C o n a g h y (2000) asserts that the "post" i n pos tco lonia l does not mean the not ion o f "after c o l o n i a l i s m " but rather explains the postcolonia l "as a place o f mul t ip le identities, interconnected histories, and shifting and 61 diverse material condi t ions . It is also a place where n e w racisms and oppressions are be ing formed" (p. 1). F o r example , i n Canada today, the l ives o f many A b o r i g i n a l people are s t i l l organized i n large part by the Indian Act. D r a w i n g o n H o m i B h a b h a (1994), M c C o n a g h y (1997) describes the pos tcolonia l as a t ime for reflecting, a m o v i n g back and forth and beyond the c o l o n i a l . T h i s ref lexive process, w h i c h characterizes the pos tco lonia l is a s ign that w e are n o w more aware o f our h is tor ica l locatedness, less sure o f the l ightness o f our p o l i c y decis ions, more alert to the poss ib i l i t y that our decisions may be c o l o n i z i n g rather than deco lon iz ing i n their consequences, more able to be responsive to n e w situations o f disadvantage and more able to correct ly analyze and redress the specifics o f loca l oppressions, (p. 86) A t this t ime w h e n diversi ty, vo ice , and choice are embraced as important considerations, pos tco lon ia l i sm takes us back and forth between ideas o f the past to solutions i n the present and the structures that create them ( M c C o n a g h y 1997). Today , as we engage i n debates about A b o r i g i n a l health and soc ia l p o l i c y issues i n the context o f mental health reform, w e need to understand that i n a sense " w e are m a k i n g decis ions about what constitutes [Canadian] c o l o n i a l i s m " and "what w e have determined to be the essential aspects o f ant i -colonia l w o r k " ( M c C o n a g h y , p. 82). O u r challenge is to determine w h e n and under what circumstances an ini t ia t ive (po l i cy or research) might be "oppress ive" and " l i m i t i n g " and w h e n i t might be "emancipatory" (p. 82). Sa id ' s (1978) foundational text, Orientalism provides a systematic chal lenge to expressions o f Wes te rn culture w h i c h takes the form o f c o l o n i a l oppress ion and dominat ion . It is a k i n d o f first phase o f pos tco lonia l theory i n w h i c h S a i d "directs attention to the 62 discursive and textual p roduc t ion o f co lon ia l meanings and, concomitant ly , to the consol ida t ion o f c o l o n i a l hegemony" (Gandh i , 1998, pp. 64-65). S a i d has been cr i t i c ized o n several fronts i n re la t ion to Or ien ta l i sm, namely, that he fai led to acknowledge the influence o f M a r x i s m i n this w o r k , that he presented an over ly essential ized image o f both the " W e s t " and the "Or ien t " and that he ignored the part that resistance and c o m p l i c i t y o f co lon ized peoples p lay i n the creat ion o f knowledge about them (Quayson, 2000 , p . 4) . Regardless, he has made an important cont r ibut ion to the f ie ld o f pos tco lonia l studies by art iculating an "analysis o f representation." V i s a v i s Or ien ta l i sm, Sa id makes the l inkage between knowledge and power , between representation and "the ul t imate const i tu t ion o f imper ia l and co lon ia l power" (p. 4) . M c C o n a g h y (2000) summarizes Or ien ta l i sm as fo l l ows : Or i en t a l i sm is a mode o f discourse w i t h support ing technologies, structures, and insti tutions; a style o f thought w h i c h enshrines certain values and aesthetic cri teria; a corporate ins t i tut ion for domina t ing and exerc is ing authority over others; and a v i t a l component o f the development o f Western economic strength, (p. 18) Or ien ta l i sm acts as an h is tor ica l informant for m y study. A l o n g w i t h its many critiques it assists i n adding to an understanding o f the l inkages between Canad ian c o l o n i a l i s m and the embeddedness o f dominan t Wes te rn ideologies i n health care insti tutions, po l ic ies , and 'everyday pract ices ' . It uncovered the extent to w h i c h c o l o n i a l ideo logy permeated vi r tual ly a l l facets o f Western knowledge , science, literature, and culture to p rov ide " a po l i t i ca l v i s i o n o f reali ty whose structure promoted a binary oppos i t ion between the fami l ia r (Europe, the West , us) and the strange (the Orient , the East, them)" (Sa id , 1978, c i ted i n L o o m b a , 1998, p. 47). H o w e v e r , the inaugurat ion o f co lon ia l discourse analysis was predated by the erudite works o f F ranz F a n o n (1967), A i m e Cesaire (1972), M e m m i (1965/1991) , and others w h o wri te i n the an t i -co lonia l genre. A l l o f these postcolonia l scholars provide the analytic apparatus to examine the ways i n w h i c h the Other has been constructed and contrasted w i t h the Wes t (Anderson , 2 0 0 1 ; M c C o n a g h y , 2000; R e i m e r K i r k h a m & Ande r son , 2002). Since Sa id , theoretical perspectives have been advanced by pos t -colonia l writers such as Stuart H a l l , H o m i Bhabha , Gaya t r i Chakrovor ty Spivak , and Chandra M o h a n t y , to name but a few, across a w i d e spectrum o f d isc ip l ines (sociology, anthropology, l i terary c r i t i c i sm, cultural studies, po l i t i c a l a c t i v i s m and analysis, psychoanalysis , and others). H e a v i l y inf luenced by postmodern and poststructuralist traditions, and more recently b y f e m i n i s m and neo-m a r x i s m , these divergent d i sc ip l inary applications preclude any single, un i f ied "enti ty" or "parad igm" o f pos t co lon ia l i sm (Reimer K i r k h a m & Ande r son , 2002 , p. 3). In the past 15 years, the prol i ferat ion o f increasingly diffuse uses o f the term "pos t co lon ia l " has r i sked diver t ing attention away from its h is tor ical processes (Ashcroft , Gr i f f i ths & T i f f i n , 1995). Nonetheless , several themes remain characteristic o f pos tco lon ia l i sm, i nc lud ing race, difference, culture, ethnici ty, nation, power, subalterns, subjectivity, identity, displacement, hybr idi ty , h is tor ica l pos i t ion ing , and the construction o f Other (Re imer K i r k h a m & Ander son , p. 3). Importantly, pos tco lon ia l i sm recognizes the c o l o n i a l project and its aftermath as an "ep i s temolog ica l malaise at the heart o f Western ra t ional i ty" (Gandhi , 1998, p. 26). Pos tco lon ia l discourses have been c r i t i c i zed for reproducing the very practices they a i m to disrupt. F i r s t ly , they have been c r i t i c ized for revert ing to the po l i t i cs o f binary opposi t ion, i.e., c o l o n i z e d and co lon ize r ( H a l l , 1996; M c C o n a g h y , 2000; Narayan , 1997), thereby ignor ing the complex i t i e s and shifting ambiguit ies o f po l i t i c a l posi t ionali t ies and 64 various forms o f resistance ( M c C o n a g h y ) . Secondly , concern has centered o n the presumption o f an essential ized, shared experience o f co lon iza t ion among members o f a group ( G a n d h i , 1998; R e i m e r K i r k h a m & Anderson , 2002). T h i r d l y , the preoccupat ion w i t h questions o f race, ethnici ty, and culture to the exc lus ion o f other forms o f c o l o n i a l oppression based o n gender, class, and nat ion carry the r isk o f p r iv i l eg ing one set o f oppressive relations over another (Re imer K i r k h a m & Anderson) . Four th ly , c i t ing A h m a d (1955), G a n d h i raises the issue o f the pos tco lon ia l intel lectual whose studied gaze at those o n the margins does noth ing to actual ly address "the real pol i t ics o f the co l l ec t iv i ty" (p. 13). A s L a R o c q u e (1996) argues, the pos tco lonia l scholar has a mora l obl iga t ion to the project o f soc ia l jus t ice (p. 11) and to praxis-oriented scholarship. Las t ly , G a n d h i highl ights S p i v a k ' s (1993) questions to the pos tcolonia l scholar w o r k i n g w i t h i n the academy - as academics, can w e pos i t ion ourselves "outside the teaching mach ine" (Sp ivak) [and as nurses outside the health institutions whose structures w e are examin ing] . C a n w e examine the margins w h i l e buy ing into part o f the center? W i t h these caveats i n m i n d , I argue for a pos tcolonia l nurs ing scholarship that is commit ted to expos ing the inequities and mul t ip le levels o f d i sc r imina t ion that face A b o r i g i n a l peoples w i t h i n the mental health care complex , and i l l u m i n a t i n g the experiences o f A b o r i g i n a l peoples to enable the creation o f transformative knowledge and praxis-oriented inqui ry . Cen t ra l to meet ing this goal i n pos tcolonia l scholarship is S p i v a k ' s (1988) question, " C a n the subaltern speak?" 7 9 According to Anderson (1998b, 2000a) transformative knowledge is "knowledge that is, first of all, undergirded by consciousness on the part of healthcare providers, and that unmasks unequal relations of power and issues of domination and subordination, based on assumptions about "race," "gender," and, class relations (p. 205, p. 225). 65 Subaltern Voices: Positioning Marginalized Voices and Knowledge A core feature o f pos tco lonia l nursing scholarship is , the deliberate decentering o f dominant culture so that the w o r l d v i e w s o f the marg ina l i zed become the starting point i n our knowledge const ruct ions . . . . a pos tco lonia l commi tment results i n the weav ing o f the perspectives and experiences o f those margina l ized i n our society into the very fabric o f our nurs ing science. (Re imer K i r k h a m & Anderson , 2002, p. 12) A s Battiste (2000) and T u h i w a i S m i t h (1999) note, Indigenous vo i ce has l ong been s i lenced i n the soc ia l sciences. " [DJehumaniza t ion and bias have been entrenched i n Canad ian studies about N a t i v e peoples" and as such vo ice needs to be used not on ly as an express ion o f "cul tural integri ty," but also as a means o f balancing this legacy ( L a R o c q u e , 1996, p. 13) Pos tco lon ia l i sm demands "the right to speak, rather than be ing spoken for and to represent oneself, rather than be ing represented, or, i n extreme cases, rather than be ing erased ent irely" (Re imer K i r k h a m & Ande r son , 2002, p. 12). Thus , vo i ce becomes a central issue i n pos tcolonia l scholarship p l ac ing responsibi l i ty o n the researcher to ensure the express ion o f subaltern perspectives. The construct ion o f knowledge located i n subaltern voices means that one must make space for c r i t i ca l examina t ion o f mul t ip le voices f rom different soc io-his tor ica l locat ions (Anderson , 2000, p. 225) "us ing strategies such as purposive sampl ing for diverse groups o f participants w i t h a range o f experiences, l is tening carefully to the accounts o f these participants, and l ibera l ly us ing their verbat im stories i n wri t ten reports" (Re imer K i r k h a m & Anderson , 2002, p. 12). Femin i s t theorists such as S m i t h (1987, 1992) and C o l l i n s (1998) agree that some soc ia l locat ions are better than others as starting points for the development 66 o f transformative knowledge . T h i s does not mean there i s not a place for knowledge developed us ing paradigms o f inqui ry other than the one here. Rather, m y interest is i n beginning inqui ry f rom A b o r i g i n a l perspectives as a w a y o f unmask ing taken-for-granted processes, often inv i s ib l e to us, that structure l ife experiences and ways o f be ing i n the w o r l d ; i n this way , h o w these processes have been produced can be examined (Anderson , p. 226) . T h i n k i n g about S p i v a k ' s question about the "subaltern v o i c e " and the pos i t ion ing o f A b o r i g i n a l vo ice raises the quest ion about who has the "r ight to speak," i n this study, a basic quest ion about whether or not n o n - A b o r i g i n a l researchers can t ru ly understand the experiences o f rac ia l iza t ion and rac ism. F o r example, there are those w h o bel ieve strongly that research i n the field o f A b o r i g i n a l health is best undertaken b y A b o r i g i n a l researchers, and, as noted earlier, those that support the posi t ion that Indigenous scholarship can be done "a long w i t h research that requires mora l dialogue w i t h and the par t ic ipat ion o f Indigenous communi t i e s" (Battiste, 2000 , p. x x ; D u r a n & Duran , 2000; L a R o c q u e , 1996). In conduct ing this research, I have taken the pos i t ion o f Re imer K i r k h a m and A n d e r s o n (2002) that "rather than pursuing the leg i t imacy o f our roles as researchers based o n one aspect o f one 's social identity, (i.e., whiteness), one 's leg i t imacy as a researcher is based o n one ' s abi l i ty to explicate the ways i n w h i c h margina l iza t ion and rac ia l iza t ion operate" (p. 13). However , attached to this pos i t ion is the need to remain attuned to the impl i ca t ions o f continued product ion o f knowledge from dominant posit ions (p. 13). La te r i n this chapter, I w i l l discuss the role o f "cul tura l safety" as a reflective device i n this endeavour. Centra l to the pos tco lonia l project is theoriz ing the nature o f " c o l o n i z e d subject ivi ty" and the assorted forms o f cul tural and po l i t i ca l resistance (Re imer K i r k h a m & Ander son , p. 67 3). Several o f the central themes o f pos tco lon ia l i sm are expanded i n the f o l l o w i n g sections i n order to offer further background. Theorizing about Racialization, Culture, Difference and Other Pos tco lon ia l scholarship integrates c r i t i ca l analyses o f the damaging effects o f "race" and " rac ia l i za t ion" w h i l e at the same t ime reveal ing "the shif t ing and inconsistent operation o f intersecting oppressions o f everyday l i f e " (Reimer K i r k h a m & A n d e r s o n , 2002, p. 2). A s social constructs ca tegor iz ing and ascr ib ing difference, race, culture, and ethnicity are often used interchangeably and w i t h l i t t le consistency when any one o f these terms is appl ied (often i m p l y i n g inferiori ty) ( M c C o n a g h y , 2000; R e i m e r K i r k h a m & A n d e r s o n , p. 3). In the next section, I w i l l examine features o f these concepts i n order to unrave l h o w c o m p l e x issues o f r ac i sm and rac ia l i za t ion interconnect w i t h issues o f culture and difference to influence relations w i t h i n heal th care. Race and Racialization A l t h o u g h the no t ion o f race as soc ia l ly constructed takes us beyond the 18 t h and 19th century understandings o f race as b i o l o g i c a l l y determined, controversies about its significance and the d i l emmas o f rac ia l injustice and conf l ic t w h i c h accompany it today are transported into the r ea lm o f po l i t i cs ( O m i & Winan t , 2002, p. 128). In this way race has been manipulated "to define, structure, and organize relations be tween dominant and subordinate groups" ( R e i m e r K i r k h a m & Ande r son , 2002 , p . 4) . O m i and W i n a n t (2002) w a r n o f the diff icul t ies inherent i n t h i n k i n g o f race as an essence or, equal ly problemat ic , as a purely ideo log ica l construct, w h i c h c o u l d be remedied us ing some " idea l nonracist soc ia l order." Rather, they understand race to be "an unstable and 'decentered' c o m p l e x o f soc ia l meanings constantly be ing transformed b y po l i t i ca l 68 struggle" (p. 121). W h i l e attempts to delineate human groups a long rac ia l l ines present serious diff icul t ies , it is their v i e w that race continues to p lay a fundamental role i n structuring and representing the soc ia l w o r l d . Thus , they bel ieve race is an element o f social structure, a d imens ion o f human representation (p. 121). It is i n this context that they posit the no t ion o f " rac ia l fo rmat ion" to s ignify "the sociohis tor ica l process by w h i c h rac ia l categories are created, inhabited, transformed and destroyed" (p. 124). A t the heart o f the rac ia l format ion process is a vast array o f " rac ia l projects" that are ideo log ica l ly and his tor ica l ly situated. These projects mediate between "the d iscurs ive or representational means i n w h i c h race is ident i f ied and s ignif ied o n the one hand, and the inst i tut ional and organizat ional forms i n w h i c h i t is rout in ized and standardized o n the other" (p. 127). A central concept o f this dissertation is that r ac ia l i z ing processes, pol ic ies , and practices have been fundamental to the co lon ia l project o f def in ing, categorizing, and order ing the l ives o f A b o r i g i n a l peoples w i t h devastating consequences: health and socia l inequities, economic and margina l iza t ion , and cont inuing negative images and stereotypes. Fanon (1967) first co ined the concept o f " r a c i a l i z i n g " condi t ions and expressions, contrasting them signif icant ly w i t h " h u m a n i z i n g " ones to suggest the ways i n w h i c h rac ia l conceptions and structural condi t ions order l ives and de l imi t human poss ib i l i t ies (Go ldbe rg & Essed, 2002, p. 6). The term " rac i a l i za t ion" was later adopted by M i l e s (1989), w h o defines it as "a process o f del ineat ion o f group boundaries and o f a l loca t ion o f persons w i t h i n those boundaries by p r imary reference to ( supposed ly) inherent and/or b i o l o g i c a l (usually phenotypic) characterist ics" (p. 74). R a c i a l i z i n g is a representational process o f categorizing or "def in ing an Other ." It is a "d ia lec t ica l process o f s ign i f ica t ion" i n w h i c h a group o f 69 people is to be understood as a supposed b io log i ca l entity (p. 75) . T h i s s igni f ica t ion then also ascribes a " s e l f identi ty b y the same cri ter ion. Issues o f race, rac ia l format ion, and rac ia l iza t ion are inherent i n the construct ion o f the Canad ian na t ion and entrenched i n the fabric o f Canad ian society: they are not insignif icant processes that w e s i m p l y m o v e beyond (Ander son & R e i m e r K i r k h a m , 1998; Henry et a l , 2000 ; R e i m e r K i r k h a m & A n d e r s o n , 2002). A s R e i m e r K i r k h a m and A n d e r s o n note, [a]s a const i tut ive element i n our c o m m o n sense, race is a k e y component o f our taken-for-granted reference schema through w h i c h w e get o n i n the w o r l d . Ind iv idua l psyches and relat ionships among ind iv idua ls are shaped by race; co l l ec t ive identit ies and socia l structures are rac ia l ly constituted, (p.4) Intersections of Racialization, Class, Race, Gender and Health A l t h o u g h pos tco lon ia l scholarship focuses attention o n "race," it is important to note that "race" does not necessari ly h o l d "the t rump card over a l l other forms o f oppressions or margina l iza t ions" (Re imer K i r k h a m & Ander son , 2002, p. 13). C o l l i n s (1990) notes that sexism, rac i sm, and c lass i sm become in ter locking categories o f analyses. In addi t ion, she observes, an i n d i v i d u a l m a y be an oppressor and the oppressed concurrently, depending o n the particular context: for example , an A b o r i g i n a l m a n m a y be p r iv i l eged b y gender but penal ized by race (ci ted i n R e i m e r K i r k h a m & Ander son , p. 13). R e c o g n i z i n g the shift ing nature o f these intersecting oppressions helps to exp la in h o w a l l groups "possess va ry ing amounts o f penal ty and p r iv i l ege i n one his tor ica l ly created sys tem" ( C o l l i n s , p . 225) and h o w mul t ip le identities coexis t (Re imer K i r k h a m & Anderson) . In this study, the no t ion o f intersectionality is used to e x p l a i n the c o m p l e x nature o f mental health care del ivery - i n 70 particular, h o w decis ions are made regarding the target popula t ion o f menta l health services and treatment modal i t ies . Race cannot be neatly sifted apart f rom processes o f rac ia l iza t ion , issues o f gender, class relations, and other soc ia l relations that structure peoples ' l ives such as their education l eve l , employment status, health, and wel l -be ing . A s Banner j i (1995) notes, [ r jacism is after a l l a concrete social formation. It cannot be independent o f other soc ia l relations o f power and ru l ing w h i c h organize the society, such as those o f gender and class (p. 128). M c C o n a g h y (2000) concurs that rac i sm "as a process o f differentiation, is integrally l i nked to other socia l processes o f differentiation and identity formation such as sex i sm, ageism, homophob ia and c lass i sm. A l l o f these processes o f differentiation are based upon a self-other b inary" (p. 42) . W h i l e rac ia l iza t ion is about "Other ing , " r ac i sm is about representing the other i n some essential ized wa y ( M c C o n a g h y , 2000, p. 42) . M a n y theorists have examined the var ious intersecting forms o f r ac i sm, inc lud ing Ban ton (1977), Essed (1991, 2002) , Essed and Go ldbe rg (2002), G o l d b e r g (1993), H a l l (1989/1996), H e n r y et al . (2000), M i l e s (1989), O m i and W i n a n t (1986/2002), So lomos and B a c k (1996), among others. A c c o r d i n g to M c C o n a g h y (2000), c o m b i n i n g ideo logica l and discurs ive theories o f r ac i sm provides powerful insights into the role o f "(con)text and text i n the format ion o f part icular racisms [r jacism is not a th ing but both a product and expression o f soc ia l relations: more accurately, rac ism is located w i t h i n specif ic social relations" (p. 34). C o m m o n to the various racisms, are their "exc lus ionary and inclusionary undertakings" ( B r o w n e , 2003 ; Go ldbe rg , 1990, p. x i v ; M c C o n a g h y , 2000) . In the next section, I w i l l examine h o w various racisms overlap and intersect to sustain socia l inequities 71 and unequal relations o f power among and w i t h i n groups as a means o f p r o v i d i n g further context for the tensions and disjunctures described later i n the dissertation. The Various Racisms A s a precursor to a l l other forms o f r ac i sm (Essed, 1990), cul tura l r a c i s m is one o f the most important f rameworks o f interpretation and meaning for rac ia l thought i n society (Henry et a l . , 2000) . It is an essential apparatus whereby the dominant group reaffirms i t se l f through image and representation, and i t is the m e d i u m through w h i c h marg ina l i zed groups are exc luded. Y e t i t is rendered v i r tua l ly inv i s ib le as it i s seamlessly w o v e n into the co l lec t ive fabric o f the dominant group v i s a v i s forms o f representation such as the mass media , the arts and re l ig ious doctrines, ideologies and practices (Henry et a l . , 2000 , pp. 56-57). A r m i t a g e (1999) describes cultural r ac i sm as "the assumption that the culture and institutions o f one group is superior to another" (p. 69). In the findings chapters o f the dissertation, I examine the ways i n w h i c h the mental health system continues its strong attachment w i t h Wes te rn w o r l d v i e w approaches to the exc lu s ion o f A b o r i g i n a l or other w o r l d v i e w s , rendering the system inaccessible for many people. F o r example , the health and i l lness be l i e f models o f A b o r i g i n a l peoples are often ignored, as reflected i n pol ices , procedures, and practices. A c c o r d i n g to Henry et a l . (2000), democrat ic r ac i sm is the most appropriate m o d e l for understanding h o w and w h y rac i sm continues i n Canada (p. 19). F o r example , i t is useful i n exp la in ing h o w Canadians can espouse l ibera l pr inciples o f equali ty, tolerance, fairness, and just ice and at the same t ime h o l d negative, rac ia l ized v i ews o f the Other , for example , A b o r i g i n a l people (Browne , 2003) . Thus , democratic r ac i sm is a " r a c i s m o f paradoxes" - i t is an ideo logy i n w h i c h two sets o f values coexist , yet necessarily conf l ic t . D e e p l y embedded i n 72 Canad ian society i n its ideo log ica l and discursive forms, democrat ic r ac i sm is d i f f icul t to challenge wi thout seemingly attacking the essence o f Canad ian va lue structures (Browne , 2001; Henry et a l , 2000; Y o u n g , 1990). C i t i n g Hebr idge ' s (1993) understanding o f "frames o f reference," H e n r y et a l . assert that democratic rac i sm is located w i t h i n socie ty ' s frames o f reference defined as a largely unacknowledged set o f beliefs , assumptions, feelings, stories, and quasi-memories that underl ie , sustain, and in fo rm perceptions, thoughts and actions. Democra t i c rac i sm as racist discourse begins i n the fami l ies that nurture us, the communi t ies that soc ia l ize us, the schools and univers i t ies that educate us, the m e d i a that communica te ideas and image to us, and the popular culture that entertains us. (Henry , 2000, p. 24) In Chapter F i v e , I discuss the w a y i n w h i c h discourses embedded w i t h i n democrat ic dec is ion-making processes, where equali ty is v i e w e d f rom a un i fo rm or undifferentiated perspective, serve unwi t t ing ly to advantage some groups over others. The (seeming) neutral izat ion o f "race" is a central feature o f democrat ic rac ism - that is , "the shift ing o f attention away f rom rac ism, rac ia l iza t ion, gender and class as intersecting processes that disproport ionately disadvantage some groups and not others" (Browne , 2003, p. 59). In this regard, several authors d raw attention to the p r o b l e m o f conf la t ing culture w i t h "race" ( G i l r o y , 2002 ; M c C o n a g h y , 2000; San Juan, 1999) no t ing h o w this tends to construct particular groups as uni ted " exc lu s ive ly i n terms o f culture and identi ty rather than pol i t ics and history" ( G i l r o y , 2000; G i l r o y , 2002, p. 251). The denia l or m i n i m i z a t i o n o f rac ia l ized inequities i n dominant institutions such as the mental health care c o m p l e x avoids confrontation w i t h the various racisms w i t h i n , for example , ins t i tut ional and ind iv idua l 73 rac ism, and discounts connections between structural inequities and disadvantage ( D y c k & Kearns , 1995). Ind iv idua l or personal r ac i sm (Armi tage , 1999) is probably the most c o m m o n l y understood fo rm o f rac i sm. At t i tudes , beliefs, stereotypes, and judgments are attached to a racial group, generally seen as inferior. A c c o r d i n g to H e n r y et a l . (2000), " i n d i v i d u a l racist beliefs provide a lens through w h i c h one sees, interprets, and interacts w i t h the w o r l d " . However , these beliefs do not occur i n a vacuum, rather, they psycho log ica l l y reflect, and are embedded in , the structure o f soc ia l relations (p. 53): Individuals are not located outside o f the socia l relations through w h i c h racisms operate (Essed, 2002) . F o r example , rac ia l d iscr iminat ion i n the fo rm o f subtle gestures and openly demeaning insults and behaviours has been observed i n many locations across B C and described by several researchers (Browne and F i ske , 2000; F i ske , 1995; Furniss , 1999). In subsequent chapters, I illustrate h o w everyday inc lus ions and exclus ions o f A b o r i g i n a l i t y w i t h i n the menta l health care system reflect and reactivate pre-exist ing soc ia l and structural inequit ies and tensions and disjunctures. Essed argues that i n some sense ind iv idua l r ac i sm m a y be a contradic t ion i n terms, since, by def ini t ion, i t depends o n "the expression or act ivat ion o f group p o w e r " for its existence (p. 179). H o w e v e r , despite the mutual interdependence o f i n d i v i d u a l and insti tutional r ac i sm ( M c C o n a g h y , 2000; O m i & Winan t , 2002) , theories o f institutional/structural r ac i sm are useful for understanding the "structural relations o f product ion" w h i c h exist i n soc ia l institutions such as the heal th care c o m p l e x , academia, and the just ice and educat ion systems. Blauner (1972) posits a no t ion o f inst i tut ional rac ism that is t ied to co lon ia l i sm . In his v i e w , "insti tutions either exclude or restrict the part icipat ion o f 74 racial groups by procedures that have become convent ional , part o f the bureaucratic system o f rules and regulat ions" (Blauner , c i ted i n San Juan, 2002 , p . 75) . S i m i l a r l y , H e n r y et a l . (2000) note the differential p r iv i l ege that these po l i c i es , practices, and procedures may "promote, sustain or entrench" for certain groups o f people, whether "d i rec t ly or indirect ly, consciously or unwi t t i ng ly" (p. 56). Essed ' s (1990, 1991, 2002) conceptual izat ion o f "everyday r a c i s m " assists i n i l lumina t ing the relat ionship between ind iv idua l and inst i tut ional d imens ions o f rac ism. The concept o f everyday r ac i sm as used by Essed is characterized by practices w h i c h have become "systemic, recurrent, and f ami l i a r " and can be "genera l ized ." T h u s , it is a fo rm o f rac ism w h i c h has been infused into the famil iar , i n v o l v i n g soc i a l i zed attitudes and behaviour and our soc ia l relations (Essed, 2002 , pp. 188-189). Essed contends that even when rac ism is attached to the cul tura l and ideo log ica l remnants o f previous h i s to r ica l processes it is not a natural and/or permanent artifact o f European history. R a c i s m is determined by a complex o f economic , po l i t i ca l , soc ia l , and organizat ional condi t ions o f society - i t is reinvented. In the same v e i n , S m i t h (1987) locates everyday soc ia l practices w i t h i n practices that reflect soc ia l organiza t ion and " r u l i n g relations" (power). In this v i e w , the structural characteristics o f a soc ia l format ion account for the existence o f r ac i sm, for example , as it exists as a p o l i c y ini t ia tor or a rationale, instead o f "be ing the product o f actions o f groups or indiv iduals formula t ing and implement ing pol ic ies that benefit par t icular groups or classes" (San Juan, 2001 , p . 45) . A c c o r d i n g to Essed (2002), everyday r ac i sm is both the manifestation o f and m e c h a n i s m by w h i c h racist beliefs and practices and soc ia l institutions are normal ized . It provides the l inkage between "macro (structural-cultural) properties o f rac ism as w e l l as the m i c r o inequali t ies perpetuating the sys tem" (p. 180). A system o f dominance is created and preserved based o n the construct o f race through specif ic socia l relations (Henry et a l . , 2000; M c C o n a g h y , 2000). In this context, ind iv idua l s [and organizations] may be unwi t t ing ly c o m p l i c i t as agents o f r ac i sm and rac ia l iza t ion by virtue o f the systematic way i n w h i c h they are soc ia l ized and exposed to "representations that just i fy Whi t e dominance" (Essed, 1991, p. 46) . A s Essed (2002) expla ins , "Structures o f rac i sm do not exis t external to agents - they are made by agents - but specif ic practices are by def in i t ion racist o n l y w h e n they activate exis t ing rac ia l inequal i ty i n the sys t em. . . " (p. 181). A s I discuss i n the f o l l o w i n g chapters, the gaps i n accessible menta l health services to A b o r i g i n a l peoples are best understood as reflections o f a who le range o f h is tor ica l ly and po l i t i ca l ly mediated relations reproduced and reinforced i n health and soc ia l po l i cy , rather than as omiss ions and erasures o f ind iv iduals per se. Nevertheless , i nd iv idua l s and agencies are impl ica ted i n soc ia l ly organized relations o f power. Culture and Culturalism A s w i t h race, the construct o f "cul ture" carries a range o f meanings ( G i l r o y , 2000; R e i m e r K i r k h a m & A n d e r s o n , 2002) w h i c h have shifted over t ime. F o r example , i n earlier t imes culture pertained to the process o f tending something, usua l ly crops or animals and then altered i n mean ing to 1 8 t h and 1 9 t h century ideas o f " c i v i l i t y " ( p . 4 ) , w h i c h , according to L o c k (1993), d is t inguished the educated and "cul tured" from the " u n c i v i l i z e d " peasants (p. 144). F r o m here the no t ion o f c i v i l i t y was gradually transformed into its more recent usage, as pertaining to modern ci t ies and their peoples, the "cul tured," versus rural peoples, the "uncul tured" (p. 144). Therefore, h o w w e have come to conceptual ize culture is h is tor ical ly and po l i t i ca l ly mediated and inf luenced by co lon ia l relations. 76 Hi s to r i c a l l y , the Western/non-Western cul tural d iv ide was a po l i t i c a l l y motivated co lon ia l construct ion. F o r example , beliefs about the "super ior i ty" o f Western culture and " infer ior i ty" o f A b o r i g i n a l cultures functioned as the rationale and mandate for co lon i a l i sm ( K e l m , 1998; Narayan , 1998, p. 89). O n the one hand, w h i l e the c o l o n i a l project was engaged i n the agenda o f ass imi la t ion and the " i m p o s i t i o n o f sameness" v i s a v i s cul tural imper ia l i sm, o n the other hand, "cul tura l difference" p rov ided the jus t i f ica t ion for the existence o f c o l o n i a l i s m b y w a y o f cul tura l essent ial ism (Narayan, p . 89). T h i s process re l ied o n the sharp binaries between Wes te rn (us) as superior and the Other (them) as inferior. Cul tu re remains di f f icul t to define today. In nursing and other health care literature, culture is c o m m o n l y presented as compr i s ing the beliefs, practices, and values o f particular ethnic or re l ig ious groups ( C u l l e y , 1996), and as a f ramework for human behaviour (Re imer K i r k h a m & A n d e r s o n , 2002 , p . 4). W i t h its roots i n "cul tura l p l u r a l i s m , " mul t icu l tu ra l i sm, the of f ic ia l state p o l i c y i n Canada (1983) and Aus t ra l i a , embraces the l ibera l no t ion o f respect for divers i ty . H o w e v e r , accord ing to L o c k (1990) one o f the diff icul t ies is that i n establ ishing boundaries as to what exact ly is a culture or an ethnic g roup . . . . a 1 9 t h century style o f th ink ing is usual ly d r awn upon i n w h i c h nation states, or large regional areas, language, re l ig ion , and even sk in co lour or other phys ica l features are taken as immutable markers, (p. 240) A l t h o u g h acknowledg ing and celebrating cul tural divers i ty i n this way has resulted i n increased pub l i c awareness and appreciat ion for the divers i ty o f peoples i n Canada, c r i t ica l ly-oriented scholars are concerned w i t h the conflat ion o f culture w i t h differences (and identity) and the l ack o f analysis o f culture as inextr icably mediated by h is tor ica l , economic , and po l i t i ca l condi t ions ( G i l r o y , 2 0 0 0 , 1 9 9 2 / 2 0 0 2 ; M c C o n a g h y , 2000; Narayan , 1998; Re imer 77 K i r k h a m & A n d e r s o n , 2002) . A l t h o u g h descriptions o f cul tura l characteristics and practices have been useful to heal th care practit ioners and researchers, they can also reinforce stereotypes and s impl i s t i c v i e w s o f part icular groups as outsiders, as different, and as Other. These cultural ist discourses also v i e w issues o f access, compl iance , and poor health status as s temming f rom cul tura l characteristics that confl ic t w i t h mainstream, routine heal th care practices rather than be ing shaped b y larger soc ia l and po l i t i ca l structures. Therefore, s impl is t ic representations o f culture as transparent, ahistorical and/or apol i t i ca l are problemat ic because o f the w a y they divert attention away f rom the under ly ing structural inequities in f luenc ing heal th and heal th care (Anderson & R e i m e r K i r k h a m , 1999). V i e w i n g health as located w i t h i n static be l i e f systems - "the cul ture" - leads us i n an entirely different d i rec t ion than loca t ing health w i t h i n " a complex network o f meanings enmeshed w i t h i n h is tor ica l , soc ia l , economic , and po l i t i ca l processes" (Ande r son & R e i m e r K i r k h a m , 1999, p . 63) . Congruent w i t h this latter idea is H a l l ' s (1997) conceptual izat ion o f culture as a process and a set o f s ign i fy ing practices through w h i c h meanings are produced and exchanged: "[cjul ture permeates a l l society" (p. 3) . G r a p p l i n g w i t h these more c o m p l e x notions o f culture can assist health care practitioners and researchers to uncover societal structures that mask the w a y people are disadvantaged o n the basis o f culture. H o w e v e r , despite g r o w i n g concerns about images o f the Other be ing reproduced through these discourses, static not ions o f culture continue to predominate i n heal th care discourses. A n examina t ion o f the complex practice and ideology o f cu l tu ra l i sm provides a structure for understanding the continuit ies between essentialized not ions o f culture, race and rac ism. Portraits o f Western , [Abor ig ina l ] , W h i t e , or the l i k e , as w e l l as the pictures o f the "cultures" that are attributed to these various groups o f people, are often fundamentally 78 essentialist. A s N a r a y a n (1998) writes: " T h e y depict as homogenous, groups o f heterogenous people, whose values, interests, ways o f l i fe , and mora l po l i t i ca l commitments are internally p lura l and divergent" (p. 94). T h i s k i n d o f Other ing confers cul tura l characteristics, differences, or identities onto members o f diverse groups, not based o n real or actual identities but rather o n stereotyped identities, and as such erases the c o m p l e x mul t ip l ic i t i es o f heterogeneous Indigenous identities and experiences i n favour o f essent ia l ized accounts. M o s t ins id ious ly , cul tural essential ism obfuscates the way i n w h i c h "cu l tu re" is transformed through the h is tor ica l , soc ia l and po l i t i ca l contexts i n w h i c h it is used. In this way , it obscures the dynamic , ever-changing quali ty o f culture (Anderson & R e i m e r K i r k h a m , 1998). A s Narayan asserts, cultures are not pre-discurs ively individuated entities to w h i c h names are then bestowed as s imple labels, but entities whose ind iv idua t ion depends o n complex discurs ive processes l i nked to po l i t i ca l agendas. M o r e o v e r , this his tor ical sensibi l i ty also needs to be attentive to the his tor ical and p o l i t i c a l processes by w h i c h part icular values and practices have come to be impu ted as central or def ini t ive o f a particular "culture". (1998, p. 93) F o r example , the difference attached to " A b o r i g i n a l " often assumes a coherent group identity w i t h i n the var ious nations and bands pr ior to their entry into soc ia l relations, m a k i n g A b o r i g i n a l people a target for stereotyping and dangerous assumptions. A s a fo rm o f rac ism, this k i n d o f Other ing is central to establishing and re inforcing unequal soc ia l relations (Browne , 2003) . Essent ial is t representations o f culture infused w i t h i n cultural ist discourses operate by assuming and creating a bifurcat ion between Western culture and non-Western cultures or between Wes te rn culture and particular other cultures ( C u l l e y , 1996; Narayan , 79 1998). A c c o r d i n g to A h m a d (1993) by "def in ing the Other (usual ly as inferior) one i m p l i c i t l y defines onesel f against that def in i t ion (usual ly as normal or super ior)" (p. 18). Increasingly, culture is used i n dominant discourses and i n health care as a me tonym for difference that impl i e s infer ior i ty (Re imer K i r k h a m & A n d e r s o n , 2002) . Often race operates i n tandem w i t h culture but as a silent subtext (Re imer K i r k h a m , p. 5). " C o m m o n applications o f the construct o f culture may draw o n h is tor ica l and c o l o n i a l notions o f race and i n so do ing , reinforce longstanding patterns o f domina t ion and inequi t ies" (p. 5). A c c o r d i n g to M c C o n a g h y (2000), cu l tu ra l i sm is "central ly about identi ty p o l i t i c s . . . i t pr ivi leges culture as an explanatory tool for k n o w i n g matters o f soc ia l difference; and it is uses culture ind iscr imina te ly to exp la in issues i n co lon ia l contexts" - for example , mental h e a l t h 8 0 (p. 43) . In the context o f p rov id ing mental health care to A b o r i g i n a l peoples, w h e n culture is used this way , w e run the r i sk o f conflat ing the culture o f A b o r i g i n a l peoples w i t h the cultures o f poverty, substance use, and dependency. W h e n images such as this are discussed as cul tura l attributes or differences, w e run the r i sk o f reart iculat ing co lon ia l images o f the Other and re inforcing unequal power relations (Re imer K i r k h a m & Anderson , 2002). M o r e ins id ious ly , by conflat ing culture w i t h rac ia l i zed characteristics, the discr iminatory s ignif icance o f cul tural characteristics becomes masked by more acceptable, neutralized te rminology (Browne , 2003; Go ldbe rg , 1993) and Other becomes normal ized and naturalized ( M c C o n a g h y , 2000) . Later i n Chapter Seven, I w i l l examine this process i n relat ion to the way i n w h i c h depression, suicide, and other menta l heal th issues have been ' no rma l i zed ' through the internal izat ion o f these identities within A b o r i g i n a l communi t ies . In the next section, I turn to explore the exportabi l i ty o f the concept o f "cul tural safety" from the health care discourse i n N e w Zea land to i n f o r m mental health po l i cy 80 discourse i n Canada . A s a researcher do ing p o l i c y research i n A b o r i g i n a l communi t ies , I use cultural safety as a too l or lens for a ref lexive process informed b y pos tco lon ia l i sm, w h i c h alerts us to the importance o f h is tor ica l , soc ia l , economic , and po l i t i c a l structures i n the analysis o f contemporary health pol ic ies as they impact the menta l health and we l l -be ing o f A b o r i g i n a l people. Firs t , I introduce the concept o f cul tural safety f rom a pos tco lonia l analyt ical perspective, and consider its relevance i n the Canad ian context. T h e n I illustrate h o w I use the concept o f cul tura l safety as a mora l discourse to i n f o r m an analysis o f mental health p o l i c y as it applies to A b o r i g i n a l people i n B C , Canada . C u l t u r a l Safety R a m s d e n (1993), a M a o r i nurse-leader i n N e w Zealand , developed the concept o f cultural safety w i t h i n a nurs ing educat ion context i n response to c o l o n i z i n g processes i n Aotea roa /New Zealand . These processes h is tor ica l ly disregarded the i l lness and health be l ie f systems o f the M a o r i , and instead p r iv i l eged those o f the dominant W h i t e culture i n the construction o f the health care system. A s R a m s d e n (1992) wri tes , cul tura l safety was designed to focus attention o n "life chances - i.e., access to health services, education and decent hous ing w i t h i n an environment where it is safe to be bo rn b r o w n - rather than lifestyles, i.e., ethnography" (p. 22) . Cu l tu ra l safety is , therefore, not about cul tural practices; rather, it invo lves the recogni t ion o f the socia l , economic , and po l i t i c a l pos i t i on o f certain groups w i t h i n society, such as the M a o r i people i n N e w Zea land or A b o r i g i n a l people i n Canada. Cu l tu ra l safety is de r ived f rom the idea o f safety as a nurs ing standard that must be met, almost l i ke an ethical standard (Polashek, 1998). A t t en t ion is focused o n health service del ivery, and o n broader system issues such as "general nurs ing po l ic ies , the nursing settings 81 i n w h i c h care is p rov ided , and the broader health care structures o f w h i c h nurs ing is a part" Q 1 (Polashek, 1998 p . 454) . Informed by a not ion o f b icu l tu ra l i sm i n N e w Zealand, cultural safety is concerned w i t h fostering an understanding o f the relat ionship between minor i ty status and health status as a w a y o f changing nurses ' attitudes f rom those w h i c h continue to support current dominant practices and systems o f health care to those w h i c h are more supportive o f the health o f mino r i t y groups (Polashek, 1998). B y acknowledg ing the inequit ies i n health care de l ivery (for example , arguing that M a o r i people i n N e w Zea land or A b o r i g i n a l people i n Canada receive less than adequate service), cul tural safety draws attention to the issues embedded w i t h i n the soc ia l and po l i t i ca l context o f health care del ivery . Cu l tu ra l safety, therefore, a ims to counter tendencies i n health care that create cul tural r i sk (or unsafety) - situations that arise w h e n people f rom one ethnocultural group bel ieve they are "demeaned, d imin i shed or d i sempowered by the actions and the de l ivery systems o f people from another culture" ( W o o d & Schwass , 1993, p. 2). Cu l tu ra l safety reminds us that it is incumbent upon a l l o f us i n health care to reflect upon the ways i n w h i c h our po l ic ies , research, and practices m a y recreate the traumas inf l ic ted upon A b o r i g i n a l people; w e need to ask i f A b o r i g i n a l people, i n particular, and a l l Canadians i n general, are be ing p laced at r isk. W e need to concern ourselves w i t h h o w health p o l i c y discourses have been shaped i n relat ion to po l i t i ca l , soc ia l , cul tura l , and economic structures, and i n re la t ion to each other, i f we are to elucidate the ways i n w h i c h certain knowledge is p r iv i l eged i n this part icular h is tor ica l per iod (Foucault , 1973). Cultural safety assumes that all nursing interactions are bicultural regardless of the number of people or the number of cultural frameworks through which messages are filtered. Nurses are taught that in every encounter, they need to reflect on their own values and beliefs as one interacts with the values and beliefs of the Other. 82 In this study, I do not use cul tural safety as something I a m l o o k i n g at, but rather as something to l o o k through, as an interpretive lens w h i c h i t se l f is be ing reflected o n and interrogated. Cu l tu ra l safety prompts the asking o f a series o f questions to unmask the ways i n w h i c h current menta l health po l ic ies , research, and practices m a y be perpetuating neoco lon ia l approaches to health care for A b o r i g i n a l people. It becomes a vehic le for translating pos tco lon ia l concerns into praxis , pushing beyond culturalist approaches to po l i cy . G i v e n these features o f cul tura l safety, I turn next to consider its relevance i n the Canad ian context. The Importability of Cultural Safety to the Canadian Context A l t h o u g h cul tura l safety has not been w i d e l y d rawn u p o n outside Aotearoa / N e w Zealand, or outside its o r ig ina l context, D y c k and Kearns (1995) and L y n a m and Y o u n g (2000) c o n v i n c i n g l y assert the transportabili ty o f cultural safety to a research context and i n particular, to the research-participant encounter as a means o f ensuring that the "digni ty and his tor ical context o f ind iv idua l s is recognized" ( D y c k & Kearns , 1995, p . 144). Several nurse-researchers are app ly ing the concept to examine health care i n v o l v i n g a number o f marg ina l ized groups i n c l u d i n g A b o r i g i n a l patients (Anderson , 1998, 2001 ; Anderson , Perry, B l u e , B r o w n e , Henderson , L y n a m et a l . , 2003; B r o w n e , F i s k e , & Thomas , 2000 ; B r o w n e & F i ske , 2000 , 2 0 0 1 ; B r o w n e & S m y e , 2003 ; R e i m e r K i r k h a m , 2000 ; R e i m e r K i r k h a m , Smye , Tang , Ande r son , B r o w n e , C o l e s et a l . , 2002; S m y e & B r o w n e , 2002). G i v e n m y o w n engagement i n p o l i c y research, I use cul tural safety not on ly to reflect on m y research relationships w i t h i n A b o r i g i n a l communi t ies , but also as a m o r a l discourse, as I examine mental health insti tutions, po l i c i e s , and practices affecting A b o r i g i n a l access to mental health care. 83 Despi te a number o f differences and distinctions between the Canad ian and N e w Zealand contexts, w h i c h add another layer o f complex i ty to the analysis w h e n consider ing the impor tabi l i ty o f cul tura l safety, i n both countries, the health consequences o f the 82 processes o f co lon iza t ion and margina l iza t ion cross geographical and po l i t i c a l boundaries. C o l o n i z a t i o n has had extremely deleterious effects. It is i n this context that cul tural safety can be used to examine the health and social relations and practices that are shaped by dominant organizat ional , inst i tut ional , and structural condit ions. Spec i f i ca l ly , I illustrate h o w cultural safety as a m o r a l discourse helps to in fo rm a cri t ique o f mental health p o l i c y as it affects A b o r i g i n a l people i n B C . Cultural Safety as a Moral Discourse Informing Policy Critique In the context o f mental health reform i n B C , I use cul tural safety to in fo rm a series o f mora l questions about the Tightness o f po l i cy decisions and actions ini t ia ted w i t h i n the dominant health sector. F o r example , do current mental health services fit w e l l w i t h A b o r i g i n a l understandings o f health, i l lness, and heal ing, or are they at odds w i t h them g iven the current soc iopo l i t i ca l environment? H o w are the myr iad soc ia l issues, such as poverty and homelessness, w h i c h serve to cur ta i l the l ife opportunities and health o f many A b o r i g i n a l people, being addressed by reform? W i l l A b o r i g i n a l people be able to get to the Reg iona l Hea l th Au tho r i t y dec i s ion-mak ing table and, i f they do, w i l l they be able to participate i n proportionate numbers? D o the po l ic ies be ing examined and " re formed" put A b o r i g i n a l 8 2 In both countries Indigenous peoples are over-represented on the negative side of the social economy, for example, unemployment and imprisonment, and under-represented on the more positive side, for example, income and education. The loss of land, cultural traditions and the erosion of language have contributed to the loss of identity in both countries (Fleras & Elliott, 1992). Generally speaking, however, the health status of Maori people is better than that of Aboriginal people in Canada. This relates, in part, to the larger representation of Maori (27%) in the overall population and the earlier presence of Maori in the political arena in New Zealand (Elliott & Foster, 1995). 84 peoples ' heal th at risk? F o r example , are they left out i n any w a y ? A s mental health reform unfolds, cultural safety also prompts us to ask a series o f mora l questions related to the broader agendas d r i v i n g reform, such as deinst i tut ional izat ion, decentral izat ion, and devolu t ion . F o r example, does the devo lu t ion o f authority to regional bodies assist A b o r i g i n a l people i n creating effective services w h i c h meet i n d i v i d u a l communi ty needs, or does this structure insert yet another layer o f c o m p l e x i t y alongside federal and p r o v i n c i a l ju r i sd ic t iona l debates regarding w h o is responsible for A b o r i g i n a l mental health? W h a t does the no t ion o f " increasing democra t iza t ion" mean for A b o r i g i n a l people? W i l l the poorer health status o f A b o r i g i n a l people be taken into considerat ion at the dec i s ion-making table? H o w do these debates create barriers to p r o v i d i n g essential services? D o these agendas support A b o r i g i n a l self-governance? In the context o f a consultat ive process, w e must also be concerned about whether or not the vo ices represented are those o f A b o r i g i n a l people or s i m p l y the rhetor ical voice o f p o l i c y makers espousing the benefits o f reform, i n the absence o f real mater ial gains for A b o r i g i n a l people. A r e A b o r i g i n a l people invo lved , and is their i nvo lvemen t mere ly symbol i c or is i t inf luent ia l and meaningful? W h a t agendas prompted reform? For example , i n B C , mental health reform occurred o n the heels o f several brutal menta l health-related deaths and the m o b i l i z a t i o n o f the B C Schizophrenia Socie ty ( B C S S ) and other important consumer-dr iven groups. H o w can the h igh suicide rates i n A b o r i g i n a l communi t i es compete w i t h other important mental health concerns i n the mainstream? These questions go beyond issues o f resource a l locat ion and equity to an interrogation o f the injustices embedded w i t h i n soc ia l , economic , and po l i t i c a l processes that impact the 85 health o f A b o r i g i n a l people. In unravel ing the complexi t ies o f the p o l i c y process, cul tural safety becomes a reflective device/interpretive lens for the process o f p o l i c y analysis. Concluding Comments T h e factors most often identif ied as contr ibut ing to the d iscrepancy i n mental health status between n o n - A b o r i g i n a l and A b o r i g i n a l people are mul t ip le and inc lude poverty, unemployment , poorer educat ion i n some communi t ies , threats to cu l tura l identity, and a poor sense o f self-worth as a result o f d i sc r imina t ion and rac i sm ( K i l s h a w , 1999; R o y a l C o m m i s s i o n o n A b o r i g i n a l Peoples, 1996a, 1996b), at both i n d i v i d u a l and systemic/insti tutional levels . These are mora l issues that nurses i n pract ice, education, research, and p o l i c y must attend to i n the p r o v i s i o n o f health care i n v o l v i n g margina l ized , disenfranchised populat ions. In research w i t h A b o r i g i n a l communi t ies , cul tura l safety provides a pos tco lonia l framework to examine unequal power relations and the soc ia l and h i s to r ica l processes that organize these relationships. The not ion o f culture i n cul tural safety i s used to address the meanings that A b o r i g i n a l people g ive to mental health and i l lness , and the needed responses to mental health issues. G i v e n the pos tcolonia l perspective used to frame this d iscuss ion, ind iv idua l , soc ia l , and po l i t i ca l meanings that A b o r i g i n a l people attribute to health and i l lness not on ly need to be recognized and respected at the mic ro l eve l but also need to be u t i l ized i n the shaping o f mental health structures, understanding that meanings shape systems and practices, and v ice versa. T h e no t ion o f safety helps us, as researchers, to focus o n health outcomes - that is , are A b o r i g i n a l people benefit ing f rom the menta l health care system as it currently exists, or does it place them at r i sk? F o r example , do su ic ide prevent ion strategies 86 address the root causes o f despair and hopelessness apparent i n m a n y A b o r i g i n a l communit ies , and fit w i t h A b o r i g i n a l perspectives? A l t h o u g h appl icable to service del ivery, research, and p o l i c y across diverse populations, it is m y v i e w that cul tural safety is part icularly useful i n the area o f A b o r i g i n a l health because o f the h is tor ica l context o f A b o r i g i n a l health and heal th care, and relations w i t h i n the po l i t i ca l economy. B y v i e w i n g cul tural safety i n this broader context, issues o f insti tutional r ac i sm and d i sc r imina t ion that continue to shape the p r o v i s i o n o f health care for A b o r i g i n a l people i n Canada can be better cr i t iqued. Cu l tu ra l safety p rov ides a means o f c r i t iquing mental health p o l i c y , research processes, and c l i n i c a l practices. The pos tcolonia l f ramework offered by cul tural safety alerts us that we need to examine not on ly current inequities manifested i n health and heal th care, but also to examine the long histories o f economic , soc ia l , and po l i t i ca l subordinat ion that are at the root o f current health and soc ia l condi t ions among A b o r i g i n a l people. Importantly, a pos tcolonia l interpretation locates these health and soc ia l condi t ions i n the structural disadvantages that shape them. These are the issues o f concern as mental health reform is unfo ld ing i n B C , not as esoteric theoretical entities, but as everyday realities in f luenc ing the l ives and health o f A b o r i g i n a l peoples. Summary Perspectives d r awn from pos tco lonia l theories provide the interpretive lens through w h i c h I approach this research. Cu l tu ra l safety, w i t h its attention to h is tor ica l power relations, assists i n focus ing m y gaze o n the nature o f the tensions between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. Together, these theoretical perspectives are used to c r i t i ca l ly examine (a) the 87 ideologies and structures underpinning the de l ivery o f menta l heal th services i n B C , (b) the pol ic ies and practices that mediate between the ideologies underp inning service del ivery and everyday practices/ barriers to accessing mental health care, and (c) the everyday practices i n mental health service de l ivery that impede A b o r i g i n a l access to menta l health services. T h e r i sk inherent i n app ly ing these perspectives l ies i n pred ispos ing researchers to focus o n some aspects o f the data and not o n others ( B r o w n e , 2003 ; R e i m e r K i r k h a m , 2000). A s noted earlier, i t i s m y intent to apply theory as an interpretive lens, so that the theory does not become a container into w h i c h the data must be poured (Lather, 1991, p . 62) . A s I go o n to exp la in i n Chapter Four , engaging c r i t i ca l ly w i t h theoretical perspectives and mainta in ing an ongoing process o f re f lex iv i ty are central to conduct ing this research. A s K e l m (1998) notes A deep understanding o f the nature o f c o l o n i a l relations and their impact upon A b o r i g i n a l l i ves , i n this case part icular ly referenced as menta l health, is essential to any process that seeks to undo the racist teachings i n our history and to promote soc ia l and p o l i t i c a l change, (p. x x i i i ) Summary of the State of Knowledge E x a m i n i n g the s ignif icance o f past co lon ia l relations is necessary to understanding current soc ia l , p o l i t i c a l , and economic condi t ions inf luencing A b o r i g i n a l menta l health and the generally poorer menta l health status o f A b o r i g i n a l peoples. A l t h o u g h there is a literature descr ibing the barriers to access to adequate A b o r i g i n a l mental health care, there is a paucity o f research e x a m i n i n g the soc ia l relations shaping the l oca l h i s tor ica l process and consti tuting the everyday w o r l d o f menta l health service de l ive ry to A b o r i g i n a l peoples. The study presented here a ims to address this gap by examin ing the nature o f the tensions and 88 disjunctures between A b o r i g i n a l understandings o f and responses to menta l health and i l lness and the current menta l heal th system. I do this by setting out to answer the f o l l o w i n g questions i n this dissertation: (1) W h a t are the everyday practices that act as barriers to access to menta l health services for A b o r i g i n a l peoples? - i.e., W h a t are the tensions and disjunctures?; (2) W h a t are the ideologies and structures underpinning the w a y mental health care is de l ivered to A b o r i g i n a l peoples - i.e., W h y the tensions and disjunctures?; and (3) H o w do inst i tut ional po l i c ies and practices support the embeddedness o f ideologies underpinning menta l heal th service de l ivery - i.e., W h a t are the patterns o f tension and disjuncture? 89 C H A P T E R F O U R R E S E A R C H D E S I G N A N D I M P L E M E N T A T I O N I n t r o d u c t i o n It is cha l lenging to do this research w h e n I, as the researcher, a m situated w i t h i n academia — an inst i tut ion i n w h i c h a Eurocentr ic w o r l d v i e w tends to dominate, often subjugating knowledge o f the non-dominant studied group. A s S m i t h (1991) articulates, what I do as a [nurse and a c a d e m i c ] 8 3 is bound to a discourse deeply impl i ca ted i n the " ru l ing re la t ions" 8 4 (p. 157). N e o c o l o n i a l ideologies and subsequent practices shift and reemerge i n different forms, often m a k i n g them diff icul t to recognize and unmask. G i v e n the central problemat ic o f this study and these concerns, I have str iven to conduct this research f rom a pos tcolonia l stance. In addi t ion, I have inc luded cr i t ica l inqui ry i n the ethnographic tradit ion because o f m y commi tmen t to a research approach commit ted to a more just soc ia l order ( D e n z i n , 1997; Lather, 1991). T h i s chapter focuses speci f ica l ly o n h o w the research was conducted. I begin w i t h the methodology gu id ing the research. Af ter a b r i e f d iscuss ion o f c r i t i ca l ethnography, I move on to elaborate o n the use o f a pos tco lonia l standpoint i n this study. I then describe the research design, the research participants, and the techniques used for gathering the data, namely, i n -depth in te rv iewing and a cr i t ique o f po l i cy . Da ta analysis procedures, cr i ter ia for evaluating the scientif ic r igor o f the research, l imita t ions o f the study, and ethical considerations are 8 31 borrow from Smith (1991) who is referring to what we do as individuals and intellectuals, and in her case, what she does as a sociologist (p. 157). 8 4 Smith (1987) articulates "ruling relations" or "ruling apparatus" as those intersecting organizing practices of educational, legal and economic institutions, and "that familiar complex of management, government administration, professions, and intelligentsia, as well as the textually mediated discourses that coordinate and interpenetrate it" to form a network of social relations (p. 108). 90 then reviewed._Final ly, I conclude the chapter w i t h a ref lexive analysis that attempts to make transparent h o w m y soc ia l loca t ion shaped the process o f research. Selecting a Design: Critical Ethnography E a r l y ethnography grew out o f an interest i n the or igins o f culture and c i v i l i z a t i o n , part icularly those considered to be less c i v i l i z e d , as i n "p r imi t i ve cul tures" ( V i d i c h & L y m a n , 1994). A s a research methodology, it has emerged f rom cul tura l anthropology and soc io logy to describe the soc ia l and cul tural wor lds o f particular races and groups (Ornery, 1988). U n d e r l y i n g traditional ethnography was an ontologica l pos i t ion i n w h i c h reali ty c o u l d be observed and descr ibed object ively. "Ethnographers connected meaning (culture) to observable ac t ion i n the real w o r l d " (Denz in , 1997, x i ) . T h i s mode o f inqu i ry i n v o l v e d entering the f i e ld (often for extended periods o f t ime), engaging w i t h the group as a participant observer, and in te rv iewing key informants , 8 5 so that the reali ty o f the selected group c o u l d be represented. T h e two m a i n cr i t ic isms o f this fo rm o f ethnography relate to the issue o f representation and the relationship between research and practice. Trad i t iona l approaches to ethnography tend to remain strongly inf luenced by the ph i losoph ica l underpinnings o f pos i t i v i sm , scient ism, and the be l ie f that one can represent an independent soc ia l reality, a l l indica t ive o f the researcher's denial o f his/her par t ic ipat ion i n the f ie ld and i n the data analysis. A l s o , these approaches have led to a debate about the extent to w h i c h ethnography c o u l d contribute to practice, the c r i t i c i sm be ing that earlier applicat ions o f ethnographic method d i d not recognize this potential (Hammers ley , 1992, p. 2). In addi t ion, f rom a pos tco lonia l , postmodern (Lather, 1991), and feminist perspective ( A l c o f f , 1991), 8 5 Although many ethnographers continue to use the term key informant, in agreement with Rodney's position (1997), I refrain from using is because it denotes a hierarchical relationship. I also prefer the word participant and use it in this text. 91 early ethnography has been c r i t i c i zed because i t pr ivi leges the pos i t ion o f the researcher and as a consequence, enables the continuance o f power inequit ies , often unwi t t ing ly becoming a reenactment o f oppressive relationships. Therefore, a n e w ethnography emerged from a per iod o f discontent w i t h earlier ethnographic traditions (Ander son , 1989). Ethnography as presented by D e n z i n (1997) is "the f o r m o f inqu i ry and wr i t i ng that produces descr ip t ion and accounts about the ways o f the l i fe o f the wr i ter and those wri t ten about" (p. x i ) . Today , ethnography is e v o l v i n g i n the context o f a pos tco lon ia l , postmodern w o r l d . Because o f g loba l iza t ion , national boundaries and identit ies have b lurred: " i t is necessary to th ink beyond the nat ion ." Subjects of study have become participants in a study and often scrut inize the text o f ethnography; f emin i sm and "queer" theory have raised questions regarding the narrative text i n terms o f gender and heterosexism; at the centre o f the project is its emancipatory a i m ; the text is focused i n the l i v e d experience; and the ethnographic text has become a "mora l , a l legor ical , and therapeutic project" (pp. x i i - x i v ) . W h i l e participant observat ion and in terv iewing continue to be used as the m a i n methods o f data co l lec t ion i n c r i t i ca l ethnography, the researcher seeks a deeper i m m e r s i o n i n the w o r l d o f the other, and a more intimate understanding. F o r some cases i n the f ie ld , this has meant taking o n a role w i t h i n the group o f study such as "sister or mother i n an extended f ami ly . " The f ie ld worke r is both a participant and an outsider (Emerson , Fre tz , & S h a w , 1995, pp. 3-4). 8 61 use the word privileged in the same sense as Alcoff (1991) uses it: "to be in a more favorable, mobile, and dominant position vis-a-vis the structures of power/knowledge in a society. Thus privilege carries with it presumption in one's favour when one speaks. Certain races, nationalities, genders, sexualities, and classes confer privilege, but a single individual (perhaps most individuals) may enjoy privilege with respect to some parts of their identity and a lack of privilege with respect to others. Therefore, privilege must always be indexed to specific relationships as well as to specific locations" (p. 30). 92 C r i t i c i s m s o f versions o f a new ethnography as methodology are that it is over ly ref lexive, rampant ly subjective, narcissist ic, and not scient if ic . H o w e v e r , the ethnography I a m proposing here moves beyond a solely text-based theory o f difference to one that is also socia l and h is tor ica l ( K i n c h e l o e & M c L a r e n , 1994), an ethnography deepened b y a cr i t ica l engagement w i t h pos tco lon ia l perspectives. A n e w ethnography reflects the v i e w that the "real w o r l d is no longer the referent for analysis ." Instead, the ethnographer recognizes that "humans l i ve i n a secondhand w o r l d o f meanings" ( D e n z i n , 1997, p . x v i ) , a w o r l d o f soc ia l constructions. Thus , the ethnographer's task is to reveal the mul t ip l e truths apparent i n others' l ives (Emerson , Fretz, & Shaw, 1995), a good fit w i t h the attention o f postcolonia l nursing scholarship to an infus ion o f subjugated knowledge and the i l l u m i n a t i o n o f the experiences o f those marg ina l i zed w i t h i n society and w i t h i n heal th care (Re imer K i r k h a m & Ander son , 2002) . From Theory to a Method of Inquiry: A Postcolonial Framework T h e pos tco lonia l method continues to evo lve f rom w i t h i n a pos tco lon ia l nurs ing scholarship as a d ia lect ic between theory and research (Re imer K i r k h a m , 2002) . A s an angle o f inqui ry , a pos tcolonia l nurs ing method incorporates several themes. F i r s t ly , as noted i n Chapter Three, the research project is v i e w e d through a po l i t i c a l lens - a pos tcolonia l framing attends to power relations w i t h an "overarching mindfulness o f h o w dominat ion and resistance mark intercultural health care encounters at i n d i v i d u a l , ins t i tu t ional , and societal l eve ls" (p. 10). Inevitably, a pos tco lonia l c r i t i ca l lens explores the "meta" themes o f "race" and its accoutrements - co lon i za t i on and rac ia l iza t ion , and so o n - and "power , " i n its many forms. Thus , a feature o f a pos tco lonia l research method is its open commi tmen t to praxis-93 oriented inquiry , w h i c h has to do w i t h unmask ing power and resource inequities i n ways that contribute to a more "just socie ty" (p. 13). Secondly , a pos tco lon ia l method locates human experience o f the everyday i n the larger contexts o f media t ing soc ia l , economic , po l i t i ca l , and h is tor ica l forces and the realities o f the tensions between these places, " s e l f and society, the l oca l and the g loba l , the particular and the un iversa l " (Re imer K i r k h a m & Ander son , 2002 , p. 11). T h e central focus o f this research is to examine and describe the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. In keeping w i t h a pos tcolonia l c r i t ica l lens, I beg in this study w i t h the s tandpoint 8 7 o f A b o r i g i n a l peoples i n B C as a point o f entry into the everyday w o r l d o f mental health service del ivery , and l i n k these experiences to the inst i tut ional and ideologica l formations w h i c h shape and are shaped by those experiences. T h i r d l y , the pos tco lon ia l method is intended to "deliberately decentre" dominant culture to feature those voices w h i c h have been displaced to the margins by dominant culture wor ldv i ews (Narayan & Hard ing , 2000; R e i m e r K i r k h a m & A n d e r s o n , 2002) . Th i s perspective does not i m p l y a c o m m o n standpoint or vo ice , but rather recognizes the heterogeneity o f people ' s experiences. A s Re imer K i r k h a m and A n d e r s o n argue, the researcher can attend to this issue by p rov id ing an opportunity for po lyvoca l i ty , us ing such strategies as purposive sampl ing for diverse groups o f participants w i t h a range o f experiences (p. 12). I w i l l discuss the use o f this sampl ing strategy later i n this chapter. 8 7 Here I am using the notion of standpoint in much the same way as Dorothy Smith (1987) and Reimer Kirkham and Anderson (2002). Smith's (1992) standpoint perspective provides "a method of thinking about society and social relations, and of doing research" (p. 91). Inquiry which begins from the everyday world of experience aims to show how those experiences are linked into and "shaped by social relations, organization, and power beyond the scope of direct experience" (p. 89). However, unlike some standpoint theorists, Smith's methodology does not imply that there is one standpoint "from which the world can be best viewed" (Campbell & Manicom, 1995, p. 8). 94 Four th ly , a pos tco lon ia l method recognizes the co-existence o f mul t ip l e identities. Informed by the w o r k o f Pa t r i c ia H i l l C o l l i n s , R e i m e r K i r k h a m and A n d e r s o n (2002) argue for an analysis o f oppressions, for example , rac ism, sexism, and c lass i sm, w h i c h recognizes them as intersecting categories o f analyses located w i t h i n " a complex mat r ix o f domina t ion i n economic , po l i t i c a l and ideo log ica l spheres" (p. 13). A s noted i n Chapter Three , i n this sense, the oppressed and the oppressor m a y be one and the same: F o r example , an A b o r i g i n a l m a n m a y be oppressed i n relat ion to h o w the no t ion o f race operates but m a y i n fact be the oppressor i n re la t ion to h o w gender operates to demean A b o r i g i n a l w o m e n . Pos tco lon ia l methods also come under scrutiny. A s R e i m e r K i r k h a m and A n d e r s o n (2002) caution, there are epis temologica l impl ica t ions w h e n a researcher takes o n race and power as preexis t ing 'me ta ' themes - the researcher runs the r i sk o f impos ing the theoretic interpretive lens v i s a v i s the participant. F o r example , i n this study, a tension was created between m y a p r io r i assumptions about r ac i sm and its embeddedness i n the everyday w o r l d o f mental health, a pos i t i on I he ld s trongly but nevertheless d i d not want to impose o n the participants. T o address this issue, R e i m e r K i r k h a m and A n d e r s o n suggest that the nature o f the researcher-participant relat ionship i n this k i n d o f praxis-oriented scholarship provides room for explora t ion o f these taken-for-granted assumptions and for tension to remain between interpretations o f the researcher and participants. In the end, the ref lexiv i ty o f the researcher is enormous ly important i n the examinat ion o f the part icular d ia lect ic between theory and research (Re imer K i r k h a m & Anderson) - i n this way , data is used to in fo rm the generation o f ideas, but at the same t ime, r o o m is left for the use o f a p r io r i f rameworks (Lather, 1991, p. 56) . 95 T h o m e (1997) reminds us o f the way i n w h i c h knowledge is shaped by this k i n d o f research orientat ion, as a soc ia l construct ion rather than as "knowledge i n the factual sense" (p. x i i i ) . S i m i l a r l y , underp inning S m i t h ' s (1992) standpoint perspective is the assumption that knowledge and experience are soc ia l ly constructed. A s C a m p b e l l (1998) expla ins , [e]xperiential data, whether f rom interviews or observations, thus in fo rm a method, a l l o w i n g researchers an entry to socia l organizat ion for the purpose o f exp l ica t ing the experiences; by expl ica t ion I mean to wri te back into the account o f experiences the soc ia l organizat ion that is immanent, but inv i s ib l e , i n them. (p. 60) Therefore, for purposes o f this dissertation, a pos tcolonia l c r i t i ca l ethnography is an appropriate veh ic le for conduct ing research focused o n examin ing and descr ib ing the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system w i t h i n a l imi t less array o f his tor ical and cul tural specif ici t ies , i nc lud ing the poorer mental health status o f A b o r i g i n a l peoples relative to their n o n - A b o r i g i n a l cohort. The Research Design A s noted i n Chapter One , the research objectives o f this study are to (1) explicate the nature/attributes o f the tensions and disjunctures, (2) identify the aspects o f these attributes that are most problemat ic to people, (3) identify the structures, practices and techniques that create the biggest barriers to a l lev ia t ing and/or w o r k i n g w i t h i n the tensions and w h i c h impede the achievement o f o p t i m u m mental health for A b o r i g i n a l people, and (4) generate recommendat ions concerning the role o f nursing i n contr ibut ing to mental health po l icy . Therefore, to meet the research objectives situated w i t h i n a pos tcolonia l framework, the research des ign and methods needed to (a) provide an opportunity for A b o r i g i n a l people to 96 describe their experiences w i t h the mental health system; (b) p rov ide an opportunity for po l i cy makers , bo th A b o r i g i n a l and non -Abor ig ina l , to explicate their experiences w i t h mental health p o l i c y development and applicat ion; and (c) p rov ide analytic insights into h o w these experiences are inf luenced by wide r ideo logica l and socia l contexts. A quali tat ive study incorporat ing in-depth interviews w i t h A b o r i g i n a l people w o r k i n g w i t h i n menta l health and related fields and w i t h A b o r i g i n a l and n o n - A b o r i g i n a l p o l i c y makers, a focus group w i t h A b o r i g i n a l care providers i n an urban center, and a cri t ique o f several menta l health po l i c ies fits w i t h these requirements. I had the expectat ion that mental health p o l i c y and consequent programs w o u l d be informed by research w h i c h provides a descr ipt ion o f the nature o f the tensions and disjunctures. The Research Setting T h e setting for this study was urban, rural , and remote B C I conducted m y interviews o n sites chosen by the participants, w h o l i v e d across a w ide range o f geographic locations. The actual locale for the interviews var ied f rom offices i n the workp lace , restaurants, and hotels, to the part icipants ' homes. A few o f the interviews conducted w i t h participants f rom more remote locat ions were conducted i n Vancouve r where they were v i s i t i n g and/or w o r k i n g at the t ime. Beginning in the Field: Building Alliances Here, I use H a i g - B r o w n ' s (1992) refraining o f the no t ion o f negotiat ing or ga in ing access to discuss what she describes as "beginning relat ionships" (p. 97), and what I w i l l refer to as building alliances i n this study. B u i l d i n g all iances has i n v o l v e d becoming immersed i n the area o f A b o r i g i n a l mental health over the past f ive years. T h e data co l lec t ion 8 8 As a nurse researcher, I think I have a comfort with the language of alliance because of my experience as a nurse therapist. As a therapist and researcher, one is trying to establish a relationship built on trust as an ally with the participants. In the field, the researcher has an opportunity to engage with those studied, "to develop mutual understandings as they work together" (Haig-Brown, 1995, p. 3). 97 for this study was in i t ia ted after w o r k i n g i n the area o f A b o r i g i n a l menta l heal th for approximately t w o years as the coordinator o f the A b o r i g i n a l M e n t a l H e a l t h Best Practices W o r k i n g G r o u p and as a consultant i n several areas i n B C , where I assisted w i t h the development and evaluat ion o f mental health programs i n several A b o r i g i n a l communi t ies . F o r the past four years, I have been connected to one B C c o m m u n i t y where I have had the opportunity to w o r k more c lose ly w i t h communi ty members and have deve loped significant all iances and friendships. In addi t ion, I a m i n v o l v e d i n a couple o f A b o r i g i n a l agencies/ organizations commi t t ed to the improvement o f A b o r i g i n a l menta l health. M o s t par t icular ly , this study was made possible by members o f the A b o r i g i n a l M e n t a l Hea l th Best Practices W o r k i n g G r o u p w i t h w h o m I was able to discuss the purpose and methods o f the study. I was chief ly interested i n the comments they migh t offer w i t h regards to the focus o f the research, g i v e n their vast and var ied experience and knowledge i n the area. Based o n their co l l ec t ive feedback, some modif icat ions were made i n re la t ion to the study. In addi t ion, the members o f the W o r k i n g G r o u p were instrumental i n assis t ing m e to access participants f rom across B C w h o w o u l d be able to discuss the nature o f the tensions and disjunctures. Several took the ini t ia t ive to contact people w h o m they thought w o u l d be part icularly helpful i n this regard. Therefore, the people w h o m I contacted for in terviews were aware o f m y purpose i n approaching them about be ing potent ial research participants. Some participants contacted me regarding their interest i n the study. In m y experience to date, the process o f bu i ld ing al l iances i nvo lves l i s ten ing and observing as w e l l as ongo ing dialogue and respectful, genuine relat ionships w i t h people i n the f ie ld . These have been foundational to this research and to m y personal l i fe . 98 Sampling Procedures In this k i n d o f research the goal was not to show the effect o f an independent variable o n a dependent var iable or to examine the nature o f the tensions and disjunctures described under contro l led situations. Rather, the goal was to examine and describe the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system - to expl icate the h is tor ica l and soc iopol i t i ca l contexts that shape those relations. T h e p r imary select ion o f participants was made o n the basis o f their ab i l i ty to reflect on and articulate their experiences and v iews regarding the nature o f the tensions and disjunctures, (i.e., the sample was selected based o n their abi l i ty to answer the research questions and speak to the issues posed by those questions). Therefore, purposive and theoretical sampl ing o f A b o r i g i n a l people w o r k i n g i n mental health and related fields and A b o r i g i n a l and n o n - A b o r i g i n a l po l icy-makers , was used. In purposive sampl ing , participants are selected according to the need i n the study. A t the outset o f the study, to answer question One - W h a t are the everyday practices that act as barriers to access to mental health care for A b o r i g i n a l people? or what are the tensions and disjunctures? - 1 conducted in-depth interviews w i t h A b o r i g i n a l people w o r k i n g i n the f ie ld o f mental health and/or related areas and conducted a focus group in te rv iew w i t h service care providers i n an urban center. T o answer quest ion T w o - W h a t are the ideologies and structures underpinning the way mental health care is de l ivered to A b o r i g i n a l peoples? or W h y the tensions and disjunctures? - 1 d i d a cri t ique o f several menta l health po l ic ies and interviewed p o l i c y participants, both A b o r i g i n a l and n o n - A b o r i g i n a l , w h o had an in-depth knowledge o f the pol ic ies related to A b o r i g i n a l health, menta l heal th reform, and the reform process. T o answer quest ion Three - H o w do inst i tut ional po l ic ies and practices support the 99 ideologies underpinning menta l health service de l ivery? or what are the patterns o f tension and disjuncture? -1 conducted in-depth interviews w i t h A b o r i g i n a l and n o n - A b o r i g i n a l po l i cy makers and A b o r i g i n a l peoples w o r k i n g i n menta l health and related fields. M a n y o f the participants i n this study are or have been grassroot providers , and several o f the participants have also accessed menta l health services, therefore, the participants i n this study speak from mul t ip le perspectives. A s noted earlier, I began the select ion o f m y sample w i t h the A b o r i g i n a l M e n t a l Hea l th Best Practices W o r k i n g G r o u p as a source o f in format ion about possible participants because o f their experience, knowledge and interest i n menta l health issues and because o f their various geographic and socia l locat ions and connections to other A b o r i g i n a l peoples, who w o u l d also be able to speak to the issues o f concern i n this research. A t the outset o f this study, I d i d not k n o w the members o f the W o r k i n g G r o u p , and i t was through the process o f conduct ing f ie ldwork , and co l l ec t ing and ana lyz ing data dur ing the research process that relationships were bui l t . Importantly, people participated i n this study f rom their o w n perspective as an A b o r i g i n a l person or n o n - A b o r i g i n a l person - they were not speaking on behal f o f others, for example , g i v i n g the perspective o f service providers or A b o r i g i n a l people per se. In fact, several o f the A b o r i g i n a l participants i n this study made it clear that although they were speaking as an A b o r i g i n a l person, they were not speaking o n behalf o f A b o r i g i n a l peoples. A s Battiste (2000) argues, there is no one representative Indigenous voice but rather mul t ip le vo ices and perspectives. Af t e r a s ignif icant p ropor t ion o f data were analyzed, theoretical s ampl ing was used to explore relevant concepts and insights ar is ing from the data w i t h par t icular participants. F o r example, after ana lyz ing the data f rom several A b o r i g i n a l participants w h o noted the 100 inv i s ib i l i t y o f A b o r i g i n a l people w i t h i n the mental health system, I recruited a focus group f rom the urban setting w i t h people w h o w o u l d be able to speak f rom a grassroots perspective o n this issue. T h i s group was recommended by another participant because o f their experience w o r k i n g w i t h a large number o f A b o r i g i n a l people w i t h mul t ip l e health concerns inc lud ing mental health and/or a lcohol and drug use issues. These participants had a great deal o f experience t ry ing to access mental health, addic t ion , and other heal th services, w i t h and/or, o n beha l f o f their cl ients . Theoret ica l s ampl ing was also used near the end o f the study to select an addi t ional t w o p o l i c y participants: one w h o was i n v o l v e d i n p lann ing services for Fi rs t Na t ions at the regional l eve l , and one w h o had designed p o l i c y at the macro l eve l . B o t h perspectives were sought i n relat ion to gathering n o n - A b o r i g i n a l po l i cy perspectives to ga in a clearer sense o f whether o r not the f indings o f the research resonated w i t h their understandings o f the wide r issues inf luencing menta l heal th care for A b o r i g i n a l people. In addi t ion , an A b o r i g i n a l participant was recruited at the end o f the study because o f the breadth o f knowledge and experience this i n d i v i d u a l br ings to the area o f A b o r i g i n a l mental health i n relat ion to the Canad ian landscape. A g a i n , this was done to gain a clearer sense o f whether or not the findings fit w i t h the perspectives o f this i nd iv idua l (Thorne, R e i m e r K i r k h a m & M c D o n a l d -Ernes, 1997). It has been noted that data f rom 15-20 people - sometimes less - can be sufficient to provide a comprehensive understanding o f a phenomenon under study (Sande lowsk i , 1995; B r o w n e , 2003) . In this study, the sample o f participants inc luded a total o f 14 A b o r i g i n a l participants w o r k i n g i n menta l health and related fields - 13 Firs t Na t ions and 1 M e t i s ; a total o f 6 p o l i c y participants - 3 A b o r i g i n a l (2 Firs t Na t ions and 1 M e t i s ) and 3 Euro-Canadians ; a 8 9 Of course, this is dependent on the phenomenon being studied. 101 total o f 9 heal th care providers i n a focus group - 2 Firs t Na t ions and 7 Euro-Canadians ; and a total o f 2 E u r o - C a n a d i a n registered nurses ( R N s ) , for a grand total o f 31 (N=31) participants. Because o f the complex i ty o f issues related to consent, a l l o f the participants were over 19 years o f age. E n g l i s h was spoken by everyone. The participants were recruited to participate i n in-depth in terviews and were presented w i t h the op t ion o f g i v i n g feedback o n the f inal draft o f the dissertation. Recruitment A g a i n , as noted earlier, I began the recruitment process through the A b o r i g i n a l M e n t a l Hea l th Best Practices W o r k i n g G r o u p , w h i c h I coordinated f rom Ju ly 1999 unt i l M a r c h 2002 through the M e n t a l Hea l th Eva lua t ion and C o m m u n i t y Consu l ta t ion U n i t (Mheccu) , Department o f Psychiatry , U B C , funded by the A d u l t M e n t a l Hea l th D i v i s i o n , M i n i s t r y o f Hea l th . In i t ia l ly , I s i m p l y discussed the study w i t h var ious members o f the w o r k i n g group, and w h e n I was ready to recruit, I took t ime to exp l a in the study at a couple o f our meetings. I also handed out project pamphlets to the group (a l l pamphlets are i n A p p e n d i x A ) . T h e pamphlets contained informat ion for the participants i nc lud ing an outl ine o f the purpose o f the project; relevant informat ion about the researcher, i n c l u d i n g contact informat ion; and the extent o f the commi tment for the participant. I asked the w o r k i n g group members to contact m e i f they were interested i n be ing i n the study and/or recrui t ing for it. T h e y were to ld that they were under no obl iga t ion to participate, and their non-part ic ipat ion w o u l d make no difference to their w o r k i n g relationships w i t h i n the group. Potent ia l participants either ca l l ed m e to say they were interested i n the study, or gave me the name o f a potential part icipant to c a l l . T h e in i t i a l participants i n the study were g i v e n extra 102 informat ion pamphlets and a couple o f them mai l ed pamphlets to other potential participants. Others telephoned contacts they thought might be interested. I had asked those participants w h o also became recruiters to c a l l me i f their contact was interested i n the study. I then telephoned the contact and set up an appointment t ime. Those participants w h o became recruiters were p rov ided w i t h more pamphlets. A s ment ioned previous ly , the pamphlets out l ined the study and inv i ted part icipat ion. Po l i cy -makers i n v o l v e d i n the design and implementa t ion o f documents related to recent mental health reform were asked to participate i n interviews through the researcher's contacts i n A d u l t M e n t a l H e a l t h and A b o r i g i n a l Hea l th D i v i s i o n , B C M i n i s t r y o f Heal th . F o l l o w i n g telephone contact w i t h the participant, a study pamphlet ( A p p e n d i x A ) was sent and an in terv iew appointment date set. The nurses i n the hospi ta l who were recruited were contacted by an on-site phys ic ian w h o gave them a pamphlet . T h e y both approached the researcher to be in terviewed. A l l o f the participants p rov ided wri t ten consent pr ior to par t ic ipat ing i n the interview after the purpose o f the study was expla ined by the researcher. Overview of Participants Aboriginal Participants Working in Mental Health and Related Fields (RP) (n=14) T h e demographic profi les o f the 14 A b o r i g i n a l participants w o r k i n g i n mental health and related fields w h o part icipated i n this study are l is ted i n Tab le 1. A l l participated i n ind iv idua l in-depth in terviews. There are 6 males and 8 females. Th i r t een o f the participants i n this group were bo rn and/or raised i n reserve communi t ies . A t the t ime o f the study, the participants reported their status and residence as fo l lows : 6 status on-reserve (2 l i v i n g o n remote reserves, 2 o n rural reserves and 2 on urban reserves), 6 status off-reserve l i v i n g i n 103 the urban setting, 1 non-status l i v i n g i n the urban setting, 1 reported that status was not appl icable and was l i v i n g i n the urban setting. The ages o f the participants ranged f rom 32 to 63 years, though the majori ty (N=12) were over age 40 . Educa t iona l levels var ied from secondary school to univers i ty . One participant had secondary school education, one had col lege and two had some tertiary education. T h e majori ty (N=9) had a universi ty education: 4 had Masters degrees, 3 had a B A , and 2 had "some univers i ty courses." A t the t ime o f the study a l l o f the participants were employed fu l l - t ime and two participants also d i d consul t ing work . T h e professional roles o f the participants inc luded 3 executive directors, 1 regional coordinator, 1 commun i ty development specialist , 1 Ch ie f , 2 adult educators, 1 counselor , 1 supervisor , 1 program administrator, 1 consultant, and 2 program managers. Policy Participants (P) (n=6) A s il lustrated i n Tab le 1, three o f the p o l i c y participants were o f Eu ro -Canad ian descent, two o f the remain ing participants identif ied as Fi rs t Na t ions , bo th non-status, and one participant ident i f ied as M e t i s . 9 0 F i v e o f the participants l i v e d and w o r k e d i n the urban setting and one i n a remote setting. The part icipants ' ages ranged f rom 38 to 62 years w i t h most o f the participants ( N - 5 ) being more than 4 0 years o l d . A l l o f the participants had some univers i ty preparation (N=6): one had "some univers i ty courses," 3 had B A s , 1 had a Masters Degree and 1 had a P h D . A t the t ime o f the study, f ive o f the participants were employed ful l - t ime i n the area o f p o l i c y 90 Despite their essentialist connotations, I have chosen to retain these categories to distinguish between the policy participants. In keeping with the work of Furniss (1999) I have used the term Euro-Canadian. She notes that this is "the accepted term in formal academic discourse to refer to the dominant segment of Canadian society" (p. xi; Browne, 2003). However, on occasion I do use the term non-Aboriginal when making comparisons across people in the dissertation. 104 and one was employed as a private consultant i n the field o f p o l i c y and menta l health. The i r professional roles inc luded 1 senior po l i cy analyst, 2 p o l i c y consultants, 1 research and p o l i c y analysis, 1 c h i e f executive officer ( C E O ) , and 1 manager, treatment and po l i cy . A l l o f the participants were experienced i n the f i e ld o f p o l i c y development and/or analysis. Focus Group Participants (F) (n=9) A s noted i n Tab le 1, t w o o f the participants were Fi rs t N a t i o n s and seven E u r o -Canadian . T h e t w o A b o r i g i n a l participants i n this group ident i f ied as status peoples, 1 l i v i n g i n an urban reserve setting and 1 off-reserve i n the urban setting. T h e part icipants ' ages ranged from 42 to 56 years (N=7) . T h e educat ion leve l o f the participants ranged f rom h igh school to universi ty. One part icipant had "some h igh school" , one had grade 10 ( L P N ) , three had col lege educat ion (1 R N ) , three had a univers i ty education (1 B A , 1 M A , 1 B S c N ) . The participants ' professional roles i nc luded 1 nurse coordinator, 5 outreach workers , 2 counselors, and 1 outreach nurse. Some o f the participants had w o r k e d i n this setting since the program was init iated. Nurse Participants (NP) (n=2) The nurses were in terviewed i n a hospi tal setting i n a remote area o f B C . One o f the nurses had been born and raised i n this area and had recently returned and the other had been w o r k i n g i n this c o m m u n i t y for several years. B o t h were E u r o - C a n a d i a n nurses who had w o r k e d i n the field for more than 15 years and both were exper ienced w o r k i n g i n the area o f A b o r i g i n a l health. T h e y w o r k e d ful l - t ime i n this setting. Table 1: Socio-Demographic Characteristics of Study Participants (N=31) Participant Ethnicity Country of Birth Age Employment Status Highest Educational Attainment Attended Residential School Accessed Alcohol and Drug (A & D) or Mental Health. Aboriginal Participants (RP) (n=U) 6 males, 8 females First Nations 13 Metis 1 Canada 14 19-30 0 31-40 2 41-50 5 51-60 5 61+ 1 Unknown 1 Full-time 14 Part-time Elementary Secondary 1 Some Tertiary 2 College 1 University 9 (includes 1 RN) Yes 5 No 9 Parents 12 Grandparents 5 Boarding School 1 A & D 3 Mental Health 3 Counselling 2 Other 1 Policy Participants (P) (n=6) 3 males, 3 females First Nations 2 Metis 1 Euro-Canadian 3 Canada 5 Other 1 19-30 31-40 1 41-50 2 51-60 2 61+ 1 Full-time 5 Part-time Consultant 1 Elementary Secondary Some Tertiary College University 6 Yes No 3 Parents 2 Grandparents n/a 3 A & D Mental Health Counselling 3 Focus Group Participants (F) (n=9) 4 males, 5 females First Nations 2 Euro-Canadian 7 Canada 2 Unknown 7 19-30 31-40 41-50 5 51-60 2 61 + Unknown 2 Full-time 9 Part-time Elementary Secondary 2 Some Tertiary 1 College 3 University 3 RN Degree 1 RN Diploma 1 LPN 1 Yes 1 No . 1 Parents 2 Grandparents 1 n/a 7 A & D Mental Health Counselling 3 2 Nurses (N) (n=2) Euro-Canadian 2 Canada 2 Unknown 2 Full-time 2 RN Diploma 2 1.1- f l I III * I T„ n/a A & D Mental Health Counselling Nations represented in this study include: Gitxsan, Sechelt, 106 Data Collection Methods and Procedures The primary tools of this ethnography are imstructured in-depth individual interviews, a focus group interview and policy critique. The critique of the documents of mental health reform, including the 1998 Mental Health Plan: Revitalizing and Rebalancing the Mental Health System in BC (RRBC, 1998) and the Best Practices documents of Mental Health Reform,9 1 took place during the interview phase of the study. I moved back and forth between the interviews, my critique of policy documents, analysis, the literature, and writing, in an iterative fashion (Anderson, 1989). Recording Fieldnotes Fieldnotes were made after each interview to contribute to the process of developing knowledge through reflection on the experience. This involved a combination of both intuitive and empathic processes, attempting to attend to what I, the researcher, found important and interesting, in combination with what was important and interesting to the participants (Emerson, Fretz, & Shaw, 1995). In this way, the writing of fieldnotes was a kind of interpretive event in this study (Denzin, 1994,1997). The fieldnotes helped me to process contextual, methodological, and theoretical insights related to the interview process. For example, I recorded "conceptual structures" that were informing what the participant was saying (Geertz, 1973). In relation to the more theoretical issues, I made notes about the research process and questions for follow-up as well as notes linking observations to the literature and theory. This assisted in organizing my evolving thoughts about analysis (this 91 The Best Practices documents included: assertive case management, (British Columbia (BC), 2000a), consumer involvement (British Columbia (BC), 2000b), crisis response/emergency services (British Columbia (BC), 2000c), family support and involvement (British Columbia (BC), 2000d), housing (British Columbia (BC), 2000e), inpatient/outpatient services (British Columbia (BC), 2000f), psychosocial rehabilitation (British Columbia (BC), 2000g), rural and remote (British Columbia (BC), 2000h, and guidelines for elderly mental health care planning (British Columbia (BC), 2001a). 107 began after the first f ew interviews) . In addi t ion, I made notations related to h o w m y o w n socia l loca t ion m a y have inf luenced the research process as w e l l as the researcher-participant relat ionship. Las t ly , qui te separate f rom the interviews, I jo t ted d o w n thoughts related to newspaper c l ipp ings that seemed relevant to the issue o f A b o r i g i n a l mental health to provide contextual insights for the study. A s Emerson , Fretz , and S h a w (1995) exp la in , recording experiences and observations is neither "s t ra ightforward" nor "transparent" - there is no one way to do it (pp. 4-5). D e n z i n (1997) challenges the ethnographer o f the 2 1 s t century to m o v e to a fo rm o f interpretive text that is increas ingly acoust ic - to create fieldnotes that reflect a m u l t i p l i c i t y o f perceptions and interpretations. A s exp la ined b y Emerson , Fretz, and Shaw, d o i n g and w r i t i n g are "d ia lec t ica l ly related and interdependent act ivi t ies" (p. 15). Transcr ib ing ( C l i f f o r d , 1990) or insc r ib ing (Geertz , 1973; D e n z i n , 1994; Lather, 1991), translating, narrating (Emerson, Fretz , & Shaw) , and tex tua l iz ing ( C l i f f o r d & M a r c u s , 1986; D e n z i n , 1997; M a r c u s , 1986) the soc ia l discourse helps the researcher to understand what has been experienced and observed i n chart ing the research course. Research as Conversation: The Ethnographic Interviews Interviews fo rmed the nucleus o f this study. In-depth, open-ended interviews were conducted i n w h i c h I exp lored the nature o f the tensions and disjunctures between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental health system. In addi t ion, one focus group in terview was conducted. Interviews w i t h A b o r i g i n a l Part icipants i n M e n t a l Heal th and Rela ted F ie lds In-depth in terv iews were conducted w i t h A b o r i g i n a l people w o r k i n g i n mental health and related fields ( R P ) to explore their experiences w i t h the tensions and disjunctures. A l l 108 fourteen participants part icipated i n one face-to-face in-depth in te rv iew w h i c h lasted for approximately 60-90 minutes. M a n y interviews were conducted i n the offices o f the participants w i t h the excep t ion o f two interviews, w h i c h were conducted i n hotels w i t h people f rom outside the l o w e r ma in land w h o were i n V a n c o u v e r o n business. O n e other in terv iew was conducted i n a restaurant and another i n m y home. A l l in terviews took place at t imes and places convenient for the participants and many o f the in terviews were quite informal (Germain , 1986). I conducted a l l o f the interviews. In addi t ion, I had short check- in telephone, emai l and face-to-face conversations w i t h some o f the participants as I w o r k e d through the data analysis. M o s t o f these took the fo rm o f check ing the accuracy o f data and i n a few cases an explorat ion related to the emerging analysis. In-depth unstructured interviews were guided by a set o f preplanned trigger questions posed by the researcher ( A p p e n d i x C ) . Subsequent questions were formed dur ing the in terv iew i n response to the part icipants ' accounts o f their experiences (Spradley, 1979). D u r i n g the interviews, I t r ied to provide adequate space for the participants to present issues they thought important for me to hear, and many participants l ed me o n to other pathways. The interviews w i t h participants evo lved i n keeping w i t h the process o f data analysis and became more specif ic as the interviews progressed and I began to look for commonal i t i es and differences. In conduct ing the in-depth interviews, al though I had c o m p i l e d a l is t o f questions to act as prompts for the participants, formal questions were kept to a m i n i m u m . There was a direct in t roduct ion to the research topic and I spent t ime w i t h the participants at the beginning o f the in te rv iew to try to get acquainted and put the participant at ease. The first 109 question I asked everyone after in t roducing the study was, D o y o u th ink there is a tension (or tensions) between A b o r i g i n a l understandings o f and responses to mental health and i l lness and the current mental heal th sys tem? , 9 2 to w h i c h almost everyone responded yes. I then m o v e d o n f rom there i n the d i rec t ion o f the participant 's response, general ly exp lo r ing the texture o f A b o r i g i n a l - n o n - A b o r i g i n a l relations. T h i s took many forms because o f the var iab i l i ty o f responses, however , most participants described a tension created by differing w o r l d v i e w s - A b o r i g i n a l and n o n - A b o r i g i n a l . Ano the r part icular focus o f the in te rv iew was related to the issue o f soc ia l change, therefore, I asked questions related to the part icipants ' experiences o f the mental health system i n terms o f its benefits and challenges and what they might change. In accordance w i t h us ing the concept o f cul tural safety as a means o f transporting pos tcolonia l concerns into praxis , the issue o f racism was exp lored w i t h many o f the participants and usual ly prompted considerable d iscuss ion. T h i s was a mechan i sm for l i n k i n g mic ro - l eve l interactions to macro- leve l issues i n the health care context. M a n y o f the participants raised the issue o f rac i sm without a quest ion prompt. A t the end o f every in terview I asked the participant, Is there anything I haven ' t asked that y o u see as important or w o u l d y o u l ike to make any further comments? A t this point, most o f the participants d i d add to a particular aspect o f earlier discussions. In-depth Interviews w i t h P o l i c y Participants - A b o r i g i n a l and n o n - A b o r i g i n a l In-depth unstructured interviews were conducted i n the same manner w i t h p o l i c y makers (P) w h o , i n addi t ion to the questions asked to the A b o r i g i n a l p rovider group, were able to speak speci f ica l ly to the process o f mental health reform and/or to the issue o f 9 2 Although I needed to clarify what I meant by "tension" for a couple of the participants, most seemed to understand the question. 110 difference from a p o l i c y maker ' s perspective ( A p p e n d i x C ) . F o r example , I asked a l l o f the p o l i c y makers w h y A b o r i g i n a l suic ide was not o n the mental health agenda. S i m i l a r to the interviews w i t h A b o r i g i n a l participants w o r k i n g i n mental health and related fields, these interviews were f o l l o w e d up w i t h short check-ins w i t h a few o f the participants, part icularly related to p r o v i d i n g current informat ion about the changes w i t h i n heal th care i n B C that had arisen since the study began. One o f the A b o r i g i n a l p o l i c y participants emai led a narrative account t w o days post in terv iew. In an informal fashion, the same part ic ipant has prov ided ongoing input i n relat ion to the data analysis. F o u r o f the in terviews were conducted i n the part icipants ' off ices and the other two interviews were conducted i n restaurants. In-depth Interviews w i t h Nurses The two registered nurses ( N ) w i t h i n a remote setting o f B C were chosen to add another perspective i n this research - that o f nurses w o r k i n g w i t h i n a hospi ta l setting w i t h A b o r i g i n a l peoples. These interviews were also unstructured and gu ided by s imi la r trigger questions ( A p p e n d i x C ) . T h e y took place dur ing the nurses' breaks i n an in formal fashion i n an empty c l i n i c r o o m i n the hospi tal . I was also able to engage w i t h these nurses i n informal chats before and after the interviews. Focus G r o u p Interview T h e focus group (F) was part o f the theoretical sample, chosen for the abi l i ty o f the participants to speak to the issue o f access to mental health care as care providers w o r k i n g w i t h a large number o f A b o r i g i n a l clients i n an urban centre. A t the beg inn ing o f the focus group, a general in t roduct ion and explanat ion o f the purpose o f the research inc luded reminders to the participants stressing that there were no correct o r incorrect answers. Af ter I l l the explanat ion o f the purpose and process o f the d iscuss ion was g iven , the participants were asked to introduce themselves. T h i s gave a l l o f the participants an opportuni ty to speak at the beginning o f the in terview. In addi t ion, a l l o f the participants were encouraged to participate i n the discussion. Some o f the same trigger questions were used as i n the in-depth ind iv idua l interviews w i t h A b o r i g i n a l participants i n the field, and as w i t h the in-depth i n d i v i d u a l interviews, questions were mod i f i ed i n response to group input. H o w e v e r , g iven that these participants were part o f a theoretical sample, I spent m u c h o f the t ime exp lo r ing earlier f indings such as the issue o f invisibility. A g a i n , at the end o f the in te rv iew, I asked the group i f they had anything to add or i f there was anything I had missed , to w h i c h they wanted to speak. D u r i n g the focus group interview, si lence was used as m u c h as poss ib le to a l l o w for ind iv idua l express ion (Sande lowsk i et a l . , 1989; S ta rzomski , 1997), and as the group progressed, I made modif ica t ions , as necessary, to the in te rv iew style. T h e focus group was audiotaped and transcribed verbat im. In order to assist w i t h the technica l p rob lem o f hav ing mul t ip le speakers, I made fieldnote jot t ings dur ing the in te rv iew as an attempt to clar i fy w h o was speaking. T h i s in te rv iew was conducted w i t h i n the c l i n i c setting i n the t ime allotted for a staff meeting - approximate ly two hours i n length. The staff p rov ided refreshments w h i c h added to the in formal ambiance o f the in terview. Policy Review/Critique In addi t ion to the interviews, several p rov inc i a l mental heal th documents were reviewed/ cr i t iqued i n c l u d i n g the 1998 M e n t a l Hea l th Plan, Revitalizing and Rebalancing British Columbia's Mental Health System ( R R B C , 1998) as w e l l as the Best Practices in Mental Health in BC documents. These seven documents inc lude : Asse r t ive Case 112 Management , ( B C , 2000a), Consumer Involvement ( B C , 2000b) , C r i s i s Response/Emergency Services ( B C , 2000c) , F a m i l y Support and Involvement ( B C , 2000d), H o u s i n g ( B C , 2000e), Inpatient/Outpatient Services ( B C , 2000f) , Psychosoc ia l Rehabi l i ta t ion ( B C , 2000g). In addi t ion, the draft document, Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities ( B C , 2001a), and the Best Practices R u r a l and Remote document ( B C , 2000h) were reviewed. Fi rs t I read through a l l o f the documents ment ioned above. T h e n I re-read them to see i f I was able to identify a language o f reform and consider bel iefs and values w h i c h reflected particular posi t ions and ideologies to provide a context for this research. Concepts and themes were developed and used to code the data. These documents were rev iewed per iodica l ly and concepts and themes were revised as appropriate. T o summarize , the mul t ip le forms and sources o f data obtained i n this study provided detailed and r i c h informat ion concerning the nature o f the tensions and disjunctures. A l t h o u g h participants were in i t i a l ly in terv iewed to in fo rm part icular questions, their perspectives were not treated as discrete entities i n the analysis o f the data. Da ta f rom the i n -depth interviews w i t h the A b o r i g i n a l participants, the po l icy-makers , and the nurses, and the focus group in te rv iew were used to i n fo rm a l l levels o f analysis , everyday practices, ideologies and structures, and institutions and po l ic ies . A b o r i g i n a l and n o n - A b o r i g i n a l voices were identif ied. A l t h o u g h this was not a lways the case, I d i d observe that grassroot providers across both groups tended to focus their attention o n access issues related to the everyday exclusionary practices they experienced i n their practice, whereas, the A b o r i g i n a l participants who were i n posi t ions o f leadership w i t h i n their organizat ions tended to focus o n access issues related to the broader barriers such as a lack o f resources and governance issues such 113 as the ju r i sd ic t iona l debate and self-governance at the p o l i c y l eve l . A s w o u l d be expected, the p o l i c y participants, A b o r i g i n a l and n o n - A b o r i g i n a l , spoke more di rect ly to issues o f inc lus ion and exc lus ion as they migh t relate to po l i cy . However , a l though many o f the questions were the same across the in terviews, some were group specif ic . A l l o f the participants focused attention o n the tensions and disjunctures as p r imar i ly related to the exc lu s ion o f A b o r i g i n a l wor ldv i ews and knowledge . Data Analysis A c c o r d i n g to S a n d e l o w s k i (1995) D a t a co l l ec t ion , analysis , and interpretation are processes that overlap temporal ly and conceptual ly i n quali tat ive w o r k ...there is no clear l ine i n quali tat ive w o r k that can be d r a w n between analysis and interpretation, as the data preparation process i t se l f triggers analysis and an analytic structure is often the basis for an interpretation, (p. 372) A s D e n z i n (1994) states, " [T]he th ick descriptions and inscr ipt ions create th ick interpretation. T h i c k interpretations interpret th ick descriptions, i n terms o f the l oca l theories that are structuring people ' s experiences" (p. 506). T h e interpreter is a lways attempting to uncover the theories and s h o w h o w they are w o r k i n g i n the l ives o f the people be ing studied through the text ( D e n z i n , 1994, 1997; Smi th , 1992). Therefore, as ment ioned earlier, the process o f analysis i nvo lves an ongoing dialogue between the data and theory (Lather, 1991). "The search is for theory w h i c h grows out o f context-embedded data, not i n a way that automatical ly rejects a p r io r i theory, but i n a way that keeps preconceptions from distorting the log ic o f ev idence" (Lather , p. 62) . In this study, an interpretive thematic analysis was comple ted us ing processes 114 descr ibed for qual i ta t ively der ived data (Anderson , 2001 ; D e n z i n , 1997; Sande lowsk i , 1995). In ethnographic w o r k such as this, the stages o f data co l l ec t ion and analysis do not occur i n a l inear fashion but rather are iterative processes (Anderson , 2000 , p. 202) . Therefore, a l though the f o l l o w i n g steps h igh l igh t the process o f analysis used i n this study, they were not necessarily sequential. Step 1: Af te r each interview, I l is tened to the tape and then sent it out for t ranscript ion; I also transcribed the fieldnotes and reread them. Step 2 : O n c e the tapes were transcribed they were checked for accuracy against the recording. Step 3: D u r i n g the data co l lec t ion per iod , I c r i t iqued the documents o f reform (noted above) i n w h i c h I was able to identify a "language o f r e fo rm" and consider beliefs and values w h i c h reflected part icular posi t ions and ideologies , as a pre l iminary step to p rov id ing a context for this research. Concepts and themes were developed and used to code the data. These documents were rev iewed per iod ica l ly and concepts and themes were revised as appropriate. Step 4: Once I had several in terviews comple ted and the transcriptions had been returned, I began to read through the complete in terv iews and fieldnotes to identify recurring, converg ing , and contradictory patterns ( M o r s e & F i e l d , 1995; Sande lowsk i , 1995). K e y concepts and pre l iminary emerging themes were recorded o n the transcripts to i n f o r m the ongo ing data co l l ec t ion process, and i n particular, revis ions o f in terview questions. In addi t ion, possible l inkages to theory were noted. P re l imina ry concepts and themes were developed and used to code the data, and, as more data was col lected, were rev iewed and rev ised as appropriate. A l l cod ing was done by me. Step 5: A s the coded categories developed, I entered large portions o f corresponding data into files under those headings as a means o f o rgan iz ing the data and p rov id ing easy access to it. Step 6: C la r i f i ca t ion o f the categories and concepts was achieved thr