Microsoft Word - 10936+cover+page.docx The International Indigenous Policy Journal Volume 12 | Issue 2 July 2021 Indigenous Trauma Intervention Research in Canada: A Narrative Literature Review Sarah Panofsky University of British Columbia, Canada, sarah.panofsky@gmail.com Marla J. Buchanan University of British Columbia, Canada, marla.buchanan@ubc.ca Roger John University of British Columbia, Canada, roger.john954@gmail.com Alanaise Goodwill Simon Fraser University, Canada, agoodwil@sfu.ca Recommended Citation Panofsky, S., Buchanan, M., John, R., & Goodwill, A. (2021). Indigenous trauma intervention research in Canada: A narrative literature review. The International Indigenous Policy Journal, 12 (2). https://doi.org/10.18584/iipj.2021.12.2.10936 Indigenous Trauma Intervention Research in Canada: A Narrative Literature Review Abstract Contemporary Indigenous mental health research is beginning to address colonization, contextualizing Indigenous health within a history of colonial relationships and inadequate mental health responses. In practice, however, dominant counselling models for mental health in Canada have neglected Indigenous perspectives and there is a paucity of research regarding interventions that address psychological trauma with Indigenous populations. We identified 11 Canadian studies that employed culturally appropriate trauma interventions within Indigenous communities. We discuss the findings in relation to the study participants, outcomes reported, and research design. Recommendations are provided to address the need for evidence-based trauma interventions that have efficacy for Indigenous people in Canada to address Indigenous historical trauma. Keywords Indigenous Peoples, mental health, historical trauma, trauma interventions, trauma counselling, Canada Acknowledgments We acknowledge the generous support for this research by the Vancouver Foundation. Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. 1 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Indigenous Trauma Intervention Research in Canada: A Narrative Literature Review It is widely accepted that Indigenous Peoples1 disproportionately experience psychological distress and poor health compared with non-Indigenous Peoples in Canada (Adelson, 2005; Gone et al., 2019; Kolahdooz et al., 2015; Statistics Canada, 2018). Contemporary Indigenous mental health research is beginning to address colonization (Nelson & Wilson, 2017) by contextualizing Indigenous health within a history of colonial relationships and inadequate mental health responses (McIntyre et al., 2017). McIntyre et al. (2017) found that epidemiological surveys of Indigenous populations in Canada, the United States, New Zealand, and Australia indicated that prevalence rates of mental health may be similar between Indigenous and non-Indigenous populations, but Indigenous Peoples experience a higher mental health burden due to higher rates of post-traumatic stress disorder (PTSD) and lack of adequate mental health care. In particular, the construct of Indigenous historical trauma has been used to explain the health disparities and elevated rates of psychological distress experienced by Indigenous Peoples (Brave Heart, 1998; Gone et al., 2019). Indigenous historical trauma is a distinct form of psychological trauma; it is understood to have originated from colonization, and its impacts are collective, encompassing cumulative adverse events that span generations (Bombay et al., 2014; Gone et al., 2019). The legacy of historical trauma is sustained by ineffective, inappropriate, and often underfunded programs and services (Adelson, 2005; Gone, 2009). Western biomedical approaches have failed to provide appropriate and adequate mental health services to Indigenous Peoples in Canada, resulting in the underuse of these services and proliferation of mental health challenges (Adelson, 2005). Importantly, dominant paradigms of health have neglected Indigenous perspectives that value holism, spirituality, relationality, and connection to the natural world (Adelson, 2005; McCormick, 2008). Counselling and psychotherapy interventions in Indigenous communities that are reliant on theories and techniques rooted in a Western biomedical model risk cultural displacement and assimilation, compounding the trauma that has already been experienced (Duran & Duran, 1995; Gone, 2004). Research on mental health interventions that address historical trauma in Indigenous communities is nascent (Adelson, 2005; Bombay et al., 2009; McCormick, 2008; Stewart & Marshall, 2017). The Truth and Reconciliation Commission (TRC, 2015) has called for closing the gap between Indigenous and non-Indigenous indicators of health, particularly mental health, by addressing the distinct health needs of Indigenous Peoples, providing sustainable funding for existing and new Indigenous healing initiatives, and recognizing the value of Indigenous healing practices. Given the gaps in knowledge regarding Indigenous approaches to mental health and well-being, we address the TRC’s Calls to Action by providing a narrative literature review of empirical studies conducted in Canada that employed culturally appropriate interventions with Indigenous Peoples. This literature review highlights studies privileging Indigenous healing practices to contribute to the development of a research base that validates Indigenous healing initiatives. 1 We use the term Indigenous to refer to the descendants of those who traditionally occupied the territory now known as Canada prior to the arrival of Europeans settlers. Aboriginal has the same meaning as Indigenous. We use Aboriginal when describing published works that used this term. In the Canadian context, the term Indigenous includes First Nations, Métis and Inuit. Status and non-Status are the legally defined categories applied to First Nations people under the Indian Act of 1876. We also occasionally use the term Indigenous in a similar manner when referring to the international context. 2 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Mental Health Context of Indigenous Peoples in Canada In 2016, there were 1,673,785 self-identified Indigenous people in Canada, making up 4.9% of the overall population. Since 2006, the Indigenous population grew by 42.5%, which is 4 times faster than the rest of the Canadian population (Statistics Canada, 2018). Despite the size and growth of the Indigenous population, accessible and culturally relevant health assessment data for Indigenous people, especially those living off reserve, is limited and must be approached with caution (Smylie & Firestone, 2015). Indigenous self-identification indicators in health data and opportunities for Indigenous leadership in the governance and management of Indigenous health data are lacking (Smylie & Firestone, 2015). In addition, health services are typically under provincial or territorial jurisdiction in Canada; however, First Nations and Inuit living in Inuit Nunangat fall under federal jurisdiction, which means health services are the responsibility of the federal government. Status First Nations and Inuit recognized by an Inuit claim organization are eligible for extended health benefits through the federal government. This jurisdictional patchwork leads to overlaps and gaps in both health services and health data. Moreover, non-Status First Nations, Métis, and Indigenous people living in urban areas have not always been identified as Indigenous Peoples in federal and provincial health data, and this exclusion has impacted their access to health services (Smylie & Firestone, 2015). Indigenous people have a life expectancy that is 12 years lower than the national average and experience higher rates of preventable chronic diseases compared to non-Indigenous people living in Canada (Statistics Canada, 2011). In 2016, Statistics Canada (2018) reported that half of children in foster care were Indigenous, Indigenous youth had high rates of mood disorders (11% of off-reserve First Nations youth and 7.8% of Métis youth), and Indigenous women were almost 3 times more likely than non-Indigenous women to be victims of violent crime. Some of the most commonly experienced mental health challenges in Indigenous communities were suicide (particularly in youth), alcoholism, violence, and depression (Kirmayer et al., 2000). In a sample of Indian Residential School Survivors, 64% were diagnosed with post-traumatic stress disorder (PTSD; Bombay et al., 2009; Brave Heart, 1998). Substance use and related harms have been identified as the top health priority by Indigenous communities (Firestone et al., 2015). In 2003, 74% of on-reserve First Nations people rated alcohol and illegal drugs as their biggest health concerns (Firestone et al., 2015). The rate of mortality due to alcohol related causes among Indigenous Peoples was almost twice that of the general Canadian population (Firestone et al., 2015). Indigenous Historical Trauma The systematic erosion of the cultural, social, economic, and spiritual structures of Indigenous Peoples historically, as well as ongoing contemporary oppression, has created historical trauma among Indigenous Peoples and within their communities (Poonwassie, 2006; Stewart & Marshall, 2017). Psychological traumatic stress is defined as the psychological, physical, and mental effects related to a painful, distressing, or shocking experience with which an individual does not have the capacity to cope (Stewart & Marshall, 2017; Straussner & Calnan, 2014). Complex psychological traumatic stress is described as: Experiences that (1) are interpersonal and often involve betrayal; (2) are repetitive or prolonged; (3) involve direct harm through various forms of abuse (psychological/emotional, physical, and sexual), neglect, or abandonment by persons who are responsible for the care, protection or guidance of others, especially youngsters and offspring (such as parents, family 3 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 caregivers, teachers, coaches, or religious advisors), or traumatic losses in those relationships; and (4) occur at developmentally vulnerable times in life, such as early childhood, or undermine important developmental attainments at any point in the lifespan. (Ford & Courtois, 2009, p. x) These constructs inform historical trauma, the “cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma experiences ... the collective, complex trauma is inflicted over generations on a group of people who share a specific identity or affiliation” (Bombay et al., 2009, p. 23). Colonial processes that have contributed to historical trauma include turning Indigenous people into wards of the State, imposing the federal reserve system in place of traditional systems of governance, providing inadequate services on reserve, racist attitudes and discrimination, coercing First Nations to forfeit their Indian Status, and removing Indigenous children from their families and communities as a part of the Indian Residential Schools System and child protection systems (Adelson, 2005; Kolahdooz et al., 2015). Research about the experiences of Holocaust Survivors and the resulting transgenerational impacts provided the foundation for the concept of historical trauma among Indigenous Peoples (Brave Heart, 1998; Bombay et al., 2009). Studies have shown that the transmission of trauma from Holocaust Survivors to their children often occurs in ways that are similar to the transmission of culture. Further, the trauma exposure of preceding generations is formative to an individual’s experience of post-traumatic stress (Danieli, 1998; Danieli et al., 2016). Transmitted effects can include a predisposition to PTSD, general psychological stress, and insecure attachment styles (Bombay et al., 2009). Mental health conditions associated with psychological trauma include depression, panic disorders, PTSD, sleep disorders, and substance abuse disorders (van der Kolk, 2014). Trauma can cause disorganized thinking and awareness, impaired judgment, slower reaction time, unhelpful coping, and hypervigilance. Trauma often results in socioeconomic disadvantages and maladaptive parenting styles, which contribute to intergenerational effects (Bombay et al., 2009; Straussner & Calnan, 2014). Survivors may see the world as unpredictable and unstable, and they may feel disempowered and helpless when facing the future (Straussner & Calnan, 2014). It is difficult to disentangle the effects of historical trauma from the everyday experiences of marginalized people living in poverty (Bombay et al., 2009). There are unique differences in how poverty is experienced among Indigenous Peoples in Canada as a result of colonial processes, which have had direct contributed to poverty and marginalization over generations (Statistics Canada, 2018). In a report from the Government of Canada (2018) entitled, Opportunity for All: Canada’s First Poverty Reduction Strategy, the federal government recognized the need to identify and co-develop indicators of poverty, both income- and non-income-based, and well-being that represent the diverse experiences of Indigenous Peoples in Canada. Non-income-based measures of poverty, such as literacy, numeracy, and youth engagement, reflect the power and opportunity to access and maintain a basic standard of living and to participate in society. Regarding Indigenous children, Beedie et al. (2019) reported that 47% of Status First Nations children live in poverty (53% of those living on reserve and 41% of those living off reserve). In addition, 25% of Inuit children, 22% of Métis children, and 32% of non-Status First Nations children live in poverty (Beedie et al., 2019). Contemporary health and social conditions experienced by Indigenous Peoples together with persistent discrimination are a continuation of historical traumas (Bombay et al., 2009; Kirmayer et al., 2008). According to Bombay et al. (2009), “poor well-being may reflect the direct actions of current events, the direct or indirect effects attributable to traumatic experiences in previous generations, or the synergy between the two” (p. 13). Duran and Duran (1995) 4 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 proposed a language for trauma that reflects an Indigenous perspective, referring to trauma as a “soul wound.” Duran and Firehammer (2017) elaborated on soul wounding as an “injury where blood does not flow” (p. 107), underscoring historical trauma as destructive to the lifeworld of a people. Indigenous Wellness There is wide diversity among Indigenous Peoples and no single Indigenous worldview; however, there are more similarities than differences between Indigenous groups, and some generalizations can be useful in distinguishing Indigenous worldviews from Western (Hart, 2016; McCormick, 2008). A worldview is defined as the way in which “a person perceives his or her relationship to the world” (Sue & Sue, 2003, p. 267), and structures an individual’s attitudes, values, opinions, and concepts, as well as how they think, understand events, and make decisions (Sue & Sue, 2003). According to Hart (2016) and Wilson (2008), within Indigenous worldviews, core beliefs and values include collectivism; balance with the natural world; a present time orientation; relationships with family and community; belonging to community, land, and the cosmos; non-verbal communication; the spirit as inseparable from body and mind; and the goodness of human nature. Non-dualistic thinking and relationality are central, and the wellness of the individual is intimately tied to the wellness of the community and the natural world. The phrase “all my relations” emphasizes that everything is connected and moving toward balance of mind, body, spirit, and heart (Hart, 2016; Wilson, 2008). Within these worldviews, Indigenous wellness is conceptualized as an active, forward moving process of healing (Stewart, 2008). Indigenous wellness is holistic, acknowledging the physical, emotional, mental, and spiritual aspects of a person in connection to family and community (Adelson, 2005). One model of Indigenous wellness is the Medicine Wheel, reflecting the interconnectedness and balance of the mental, spiritual, emotional, and physical aspects of health. These four realms represent the Four Directions, which signify the relationships among health, place, belonging, and the natural world, and the balance that exists between all things. Within this understanding, illness stemming from imbalance, including mental illness, must be addressed in a holistic way (Czyzewski, 2011; Kirmayer et al., 2008; McCormick, 2008; Stewart & Marshall, 2017). The individual is understood as being embedded within a web of relationships of family, Clan, ancestors, animals, nature, and the spirit world. Relationship and interdependence are central to health (Czyzewski, 2011; Stewart & Marshall, 2017). Healing from an Indigenous perspective involves helping people to understand their belonging in the overall cosmos including the social, natural, and spiritual worlds (Duran et al., 2008). Another dimension of meaning beyond individual psyche and the social world is spirituality, which can create a sense of connection, calm, clarity, and purpose within people. A person’s relationship to the land is marked by custodianship, an attendance to the needs of the land for the mutual benefit of the people and other living things that depend on it, and to the needs of the land itself. Many Indigenous traditions are characterized by a strong sense of place in which connection to land has spiritual, ethical, aesthetic, and historical dimensions and is central to resilience (Kirmayer et al., 2008). Indigenous comprehensive understandings of wellness that value holism, relationality, spirituality, and connection to the land translate poorly into the individualism and secular humanism of the Western biomedical context of care (Duran & Duran, 1995; Hart, 2016; McCormick, 2000, 2008). 5 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Identified Areas for Research and Practice The need for empirical research in the field of trauma and mental health that is collaborative with Indigenous communities and culturally relevant has been widely documented (Adelson, 2005; Bombay et al., 2009). Culturally relevant interventions are either developed for a distinct cultural group (culturally grounded) or adapted for use in a cultural group (culturally adapted; Gameon & Skewes, 2020). Existing research on mental health interventions with Indigenous Peoples points to the indelible link between cultural continuity2 and positive health outcomes (Bombay et al., 2009; Chandler & Lalonde, 2008), and the need for community-based interventions that are rooted in cultural models of health and healing and control of resources by Indigenous Peoples (Stewart & Marshall, 2017). Research that is “inclusive, engaged and empowering” (Adelson, 2005, p. S59) is severely underrepresented in the literature, necessitating decolonizing methodologies and research that incorporates meaningful dialogue with communities (Adelson, 2005). Decolonizing methodologies and trauma interventions entail addressing oppression and colonization. Decolonization criticizes and challenges colonialism, legitimizes Indigenous knowledge, and centres on liberatory healing practices (Duran et al., 2008). Similarly, community capacity building is needed to strengthen a community’s own ability to respond to health issues. More promising approaches are “ground-up” and “from the inside” (White, 2007). Critically, “unless theory, practice, and research are deeply rooted in the life-world metaphor of the culture, effectiveness will be limited at best and more trauma will occur at worst” (Duran & Firehammer, 2017, p. 122). A Narrative Review of the Literature A preliminary search of the literature was conducted to develop the design for the present review. This preliminary search established that there have been very few empirical studies about culturally relevant trauma interventions with Indigenous Peoples. We understood culturally relevant interventions to include approaches that were culturally grounded and/or culturally rooted interventions (Gameon & Skewes, 2020). There have been two systematic reviews about psychotherapy research with Indigenous communities (Drawson et al., 2016 [n = 9]; Pomerville et al., 2016 [n = 20]). These reviews focused on studies based in the United States that targeted suicide prevention, substance use disorders, anxiety and depression, general mental health, psychological trauma, and PTSD. Pomerville et al. (2016) included three Canadian studies [cited studies Dell & Hopkins, 2011; Gone et al., 2009, 2011; Thomas & Bellefeuille, 2006], and Drawson et al. (2016) included no Canadian studies. All of the studies reviewed looked at integrated Indigenous and Western approaches to psychotherapy. There has been one systematic review, which compiled 15 studies representing 10 interventions, that specifically looked at trauma interventions in Indigenous communities (Gameon & Skewes, 2020). Gameon and Skewes (2020) reviewed culturally adapted and culturally grounded trauma interventions, including three Canadian studies [cited studies Heilbron & Guttman, 2000; Marsh et al., 2016; Thomas & Bellefeuille, 2006]. To date, there have been no systematic literature reviews related to trauma interventions looking 2 Cultural continuity describes community level variables that measure the preservation of culture and self-determination (Chandler & Lalonde, 2008). Signs of cultural continuity are settled land claims; self-government; community control of education services, police and fire services, health services; and cultural facilities within the community. Research has found the prevalence of cultural continuity in Indigenous communities is strongly related to lower incidences of youth suicide. In other words, communities with stronger cultural continuity proved to have less suicide. In particular, communities with some form of self-government had the lowest rates of youth suicide (Chandler & Lalonde, 2008). 6 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 exclusively at the Canadian context, which is needed given the Canadian history of colonization and the current state of reconciliation following the TRC and the National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG). The purpose of this study was to explore the research literature that utilized culturally relevant trauma interventions with Indigenous Peoples in Canada. Following from the aim of the present study, research questions were developed to structure the literature review process: • What themes and trends are found in the literature on trauma interventions with Indigenous Peoples in Canada in terms of (a) study participants, (b) type of interventions, (c) highlights of findings, and (d) research design? • What are the strengths and gaps in the literature base? • What are the recommended future directions and opportunities for growth in trauma interventions with Indigenous Peoples in Canada that utilize an Indigenous approach? Methods We followed a narrative literature review method for the present study because of its comprehensive approach and ability to consolidate the existing literature into a unified story about culturally appropriate trauma interventions with Indigenous Peoples in Canada (Baumeister & Leary, 1997; Green et al., 2006; Record-Lemon & Buchanan, 2017). Themes constructed through a narrative literature review can help to distinguish strengths, gaps, and recommended future directions and opportunities for growth in the research area (Green et al., 2006). For the present review, we consulted methodological guidelines (Baumeister & Leary, 1997; Green et al., 2006) to establish the following steps: (a) a guided keyword search utilizing electronic databases, (b) a search of reference lists from articles found through the keyword search, and (c) an examination of the literature base according to relevance and inclusion and exclusion criteria. Procedures Guided Computerized Database Search The following databases were searched for the present literature review: the University of British Columbia Library, Google Scholar, Academic Search Complete, Education Source, PsycARTICLES, PsycINFO, ERIC, and the Wiley Online Library. Keywords utilized in this search included combinations of trauma, Indigenous, and therapy keywords, including “post-traumatic stress,” “historical trauma,” “intergenerational trauma,” “Aboriginal,” “First Nation,” “Inuit,” “Métis,” “counselling,” “psychotherapy,” “intervention,” and “Canada.” Reference List Search The reference lists of the articles obtained through the literature search were scanned for cited articles that were relevant to the present literature review. 7 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Literature Set Examination The literature set was examined for relevance by reading the article abstracts for matches with the present study’s keywords. Duplicate studies were removed. Following a duplication and title and abstract screening process, the articles were more thoroughly examined according to the inclusion and exclusion criteria. These guidelines were established to identify the full range of empirical studies on culturally appropriate trauma intervention research with Indigenous Peoples in Canada. Inclusion criteria for literature in the present study were as follows: (a) empirical investigations that employed clearly delineated methodology, (b) conducted in Canada, (c) conducted with Indigenous individuals or communities, (d) included culturally relevant interventions, (e) focused on trauma or post-traumatic stress, (f) published in peer-reviewed journals or dissertations, and (g) published in the English language. Date restrictions were not specified. Exclusion criteria for literature in the present study were as follows: (a) non-empirical and theoretical studies, (b) conducted outside of Canada, (c) not conducted with Indigenous individuals or communities, (d) did not utilize a culturally appropriate approach to interventions, (e) not focused on trauma or post-traumatic stress, (f) not published in peer-reviewed journals or dissertations, and (g) not written in or translated into English. Results Records identified during database and manual searching yielded 162 results (see Figure 1). Nine articles and two dissertations were examined for themes based on the criteria outlined above. The 11 documents found encompassed eight interventions (see Table 1). The two dissertations (Linklater, 2011; Shrigley, 2019) were included because of direct relevance to the research questions. Although the dissertations did not evaluate unique interventions, they provided a broad analysis of trauma interventions from the perspective of Indigenous clients and mental health professionals. The search was done in June of 2020 and the dates of publication ranged from 2000 to 2019. The majority of the studies (n = 8) were published in the last 10 years, between 2010 and 2020. The articles were published in a range of peer-reviewed journals across the fields of community psychology, clinical psychology, counselling, Indigenous policy, addictions, mental health, and Indigenous mental health. Research Trends Study Participants Participants in these studies included self-identified Indigenous adult clients, counsellors, traditional healers, traditional counsellors, and program administrators. Four studies took place on reserve, three studies occurred in urban settings, and one study included Indigenous healthcare practitioners from Canada and the United States. All clients, counsellors, and administrators who were participants in the studies self-identified as Indigenous, including Algonquian (Gone, 2009, 2011), Ojibway (Heilbron & Guttman, 2000), Anishnaabe (Linklater, 2011; Marsh et al., 2016, 2018; Reeves & Stewart, 2014, 2017; Shrigley, 2019), Métis, Cree, Tlaxcaltec, Dakota Sioux, Mohawk, and Cree-Métis (Linklater, 2011). Two studies did not specify the cultural group of their participants (Thomas & Bellefeuille, 2006; 8 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Thomas et al., 2013). The majority of the research occurred in Ontario (n = 7), one study was conducted in Manitoba, and one in British Columbia. Several studies included interventions that attracted Indigenous Peoples from a variety of communities (Linklater, 2011; Reeves & Stewart, 2014, 2017; Thomas & Bellefeuille, 2006). Sample sizes were small across studies, ranging from 3 to 19 participants. Figure 1. Screening Process for Included Studies Records identified through database searching n = 105 Sc re en in g In cl ud ed El ig ib ili ty Id en tif ic at io n Duplicates excluded n = 22 Abstract screening n = 83 Records excluded - Non-empirical n = 57 - Master’s theses n = 4 Full-text articles assessed for eligibility n = 22 Full-text articles excluded - Non-Indigenous focus n = 6 - Non-trauma focus n = 5 Studies included in narrative review n = 11 9 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 1 Gone, J. P. (2009). A community- based treatment for Native American historical trauma: Prospects for evidence-based practice. Northern Algonquian reservation 19 administrators, counsellors, and clients Qualitative design: Discovery-oriented methodology, open-ended interviews, extended life narratives, participant observation, program records, ethnographic materials, thematic analysis Community consent and approval prior to data collection Psychoeducational lectures, one-on-on counselling, crisis counselling, community-based activities (workshops, fieldtrips, cultural activities), 12 Steps of Alcoholics Anonymous, inner child explorations, guided imagery, meditation and visualization, anger discharge, acupuncture, neurolinguistic programming, genogram mapping, reiki, energy work, cosmo therapy, smudging, talking circles, tobacco offerings, Pipe Ceremonies, Sweat Lodge rituals, fasting camps, blessing rites 10 weeks Key themes: Emotional burdens, cathartic disclosure, self-as- project reflexivity, and impact of colonization 10 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 2 Gone, J. P. (2011). The Red Road to wellness: Cultural reclamation in a Native First Nations community treatment center. Northern Algonquian reservation 19 administrators, counsellors, and clients Qualitative design: Open-ended interviews, participant observation, program records, ethnographic materials, thematic analysis Community permission negotiated prior to research, draft report reviewed by Lodge administrators and staff, article submitted to program staff for comment Psychoeducational lectures, one-on- one counselling, field trips, cultural events, participation in ceremonies, community education, outreach activities 10 weeks Key themes: Orchestrating the therapeutic, traditional ways, and healing discourse 3 Heilbron, C. L., & Guttman, M. A. J. (2000). Traditional healing methods with First Nations women in group counselling. Ojibway reservation Three Ojibway women (focus of study), two non- Aboriginal women participated in intervention (not included in data collection) Qualitative design: Analysis of group therapy transcriptions, open-ended evaluation forms Collaboration with Native Women’s Committee, group counselling meetings held at a Native Social Services branch of the reserve where the participants lived Healing circle and cognitive therapy, purification ceremony, traditional medicines (sage, sweet grass, cedar, tobacco), opening prayer 10 weeks Key themes: Inclusion of traditional ceremony and beliefs appeared to increase therapeutic effectiveness, community healing must be addressed as well as individual healing, healing circle provided safe and spiritually nurturing environment, and complexities faced by non-Aboriginal counsellors 11 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 4 Linklater, R. (2011). Decolonizing trauma work: Indigenous stories and strategies (Dissertation). Canada Eight Indigenous healthcare practitioners from across Canada, two Indigenous healthcare practitioners from the United States Qualitative: Storytelling as methodology, interview process, decolonizing research objectives Guidance from Elders, cultural Protocols Honouring spirit and spirituality, interconnected, Medicine Wheel approaches, identity development, connecting with family, community involvement, teachings and cultural resources, restorative justice practices Not specified Key themes: Wellness in Indigenous communities, wholistic healing with Indigenous Peoples, psychiatry and Indigenous Peoples, helping with trauma, helping with depression, and helping with experiences of parallel and multiple realities 12 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 5 Marsh, T. N., Cote- Meek, S., Young, N. L., Najavits, L. M., & Toulouse, P. (2016). Indigenous Healing and Seeking Safety: A blended implementation project for intergenerational trauma and substance use disorders. Atikameksheng Anishnawbek First Nation 24 participants who identified as Ojibway, Cree, and Métis Mixed methods design: Two-Eyed Seeing, Indigenous decolonizing methodology, questionnaire, semi-structured interviews, and sharing circle Elders, community informants, and Aboriginal advisory, Indigenous supervisor, Aboriginal committee member, Indigenous intervention facilitators Seeking Safety Western treatment model, Medicine Wheel, Sweat Lodge ceremonies, smudging, drumming, sharing circles, sacred bundle, traditional healers, Elder teachings, and herbal medicines 13 weeks Key themes: Healing through traditional Indigenous methods; impact, education, and knowledge through the Seeking Safety sharing circles; awareness, understanding, and the link between substance use, trauma and the impact of colonization; and integration and application of knowledge All participants showed significant improvements in reported substance use and intergenerational trauma symptoms Five women regained custody of their children 13 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 6 Marsh, T. N., Marsh, D. C., Ozawagosh, J., & Ozawagosh, F. (2018). The Sweat Lodge ceremony: A healing intervention for intergenerational trauma and substance use. Atikameksheng Anishnawbek First Nation 24 participants who identified as Ojibway, Cree, and Métis Qualitative design: Two-Eyed Seeing, Indigenous decolonizing methodology, semi-structured interviews and sharing circle Elders, community informants, Aboriginal advisory board, Indigenous supervisor, Aboriginal committee member, and Indigenous intervention facilitators Sweat Lodge ceremonies 13 weeks Key themes: Sweat Lodge ceremony helped with spiritual, emotional, and physical healing; restoring bonds; regaining trust in self; safety; connection to others 7 Shrigley, T. L. (2019). Understanding Indigenous women’s experiences of engaging in activities to heal from intergenerational trauma (Dissertation). First Nations community in Southwestern Ontario Four Indigenous women who experienced and engaged in healing activities to recover from trauma, including intergenerational trauma Qualitative design: In-depth interviews, interpretative phenomenology, decolonizing research intent Collaboration with a First Nations social services agency Reconnection to language, ceremony, ancestry, spirituality, connection to community, interconnectedness, and one-on-one counselling Variable Key themes: Complexity of healing from intergenerational trauma, motherhood as a catalyst for change, counselling as a transformational healing activity, (re)connection to Indigenous worldviews, and interconnectedness In order to work with Indigenous populations, mental health therapists must be trauma- informed, resilience- informed, culturally informed, and culturally humble 14 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 8 Thomas, W., & Bellefeuille, G. (2006). An evidence-based formative evaluation of a cross cultural Aboriginal mental health program in Canada. Winnipeg, Manitoba Six residential school Survivors Qualitative design: Focus groups, conversational interviews Intervention recruitment through Aboriginal organizations Healing circle & focusing oriented therapy integration 12 weeks Key themes: Value of experiential knowledge, relationships among all parts of Creation, spirituality and connectedness, empowerment, self- awareness, and focusing 9 Thomas, G., Lucas, P., Capler, N. R., Tupper, K. W., & Martin, G. (2013). Ayahuasca-assisted therapy for addiction: Results from a preliminary observational study in Canada. Rural First Nations community (reserve) in British Columbia 11 Band members Mixed methods design: Difficulty in Emotion Regulation Scale (DERS), the Philadelphia Mindfulness Scale (PHLMS), the Empowerment Scale (ES), the Hope Scale (HS), the McGill Quality of Life survey (MQL0, 4 Week Substance Use Scale (4WSUS), State of Consciousness Questionnaire (SOCQ), semi- structured interviews Collaboration with band office, preparation of Longhouse for retreat by Elders Ayahuasca-assisted group therapy, Working with Addiction and Stress Retreats 2- and 4-day retreats Statistically significant (p < 0.05) improvements for hopefulness, empowerment, mindfulness, quality of life meaning, and outlook Self-reported alcohol, tobacco, and cocaine use declined; cannabis and opiate use did not Participants reported positive and lasting changes from retreats 15 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 Table 1. Culturally Relevant Trauma Interventions within Indigenous Populations in Canada (continued) Article author Location of study Study participants Research design Community involvement Type of interventions Duration of intervention Highlights from the findings 10 Reeves, A., & Stewart, S. L. (2014). Exploring the integration of Indigenous healing and Western psychotherapy for sexual trauma Survivors who use mental health services at Anishnawbe Health Toronto. Toronto, Ontario 10 traditional mental health workers Qualitative design: Indigenous decolonizing methodology, story-based interviews Carried out in partnership with Anishnawbe Health Toronto, guided by Anishnawbe Elders, researchers were employed at the agency, researchers attended Sweat Lodge ceremonies throughout the study Indigenous healing and Western psychotherapy for sexual trauma Survivors Unspecified Key themes: Loss and recovery; positive identity work through connection with Indigenous cultural wisdom, teachings, and spirituality; and integrative practices that include Western psychotherapy 11 Reeves, A., & Stewart, S. L. (2017). Healing the spirit: Exploring sexualized trauma and recovery among Indigenous men in Toronto. Toronto, Ontario 10 Indigenous mental health frontline workers (traditional Indigenous counsellors or traditional Indigenous healers). Six male Survivors of sexualized trauma Qualitative design: Decolonizing in intent, narrative inquiry, gendered lens Carried out in partnership with Anishnawbe Health Toronto (AHT), research questions were raised by AHT, research was approved by the staff and board of directors and took place under guidance of the executive director No specific interventions: Participants had been accessing counselling for six months prior to the study Unspecified Key themes: Patriarchy as a colonial wound to men, sexualized trauma as psychological trauma, isolation and shame, therapy and healing 16 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 Characteristics of Interventions All studies described the integration of Indigenous and Western approaches to trauma interventions; however, what integration entailed varied widely. In Thomas et al. (2013), an ayahuasca ceremony was combined with Western group therapy for addiction and stress. In Thomas and Bellefeuille’s (2006) study, focusing oriented therapy was applied collectively through healing circles. Marsh et al. (2016, 2018) described the integration of Seeking Safety, a Western treatment model, with Indigenous healing practices including the Medicine Wheel, sharing circles, Sweat Lodge ceremonies, smudging, drumming, the use of sacred bundles, and the guidance of traditional healers and Elder teachings. In Gone’s (2009, 2011) research, psychoeducational lectures about trauma and colonization were integrated with the 12 Steps of Alcoholics Anonymous, one-on-one counselling, the Medicine Wheel, field trips, cultural events, and participation in ceremonies. Reeves and Stewart (2014) described the integration of Sweat Lodge ceremonies and Western psychotherapy. Many interventions included facilitation by traditional healers and Elders, alongside counsellors (Gone, 2009, 2011; Marsh et al., 2016, 2018; Thomas et al., 2013; Reeves & Stewart, 2014). In Thomas et al., 2013, a Peruvian Ayahuasquero facilitated the ayahuasca ceremony. The study by Marsh et al. (2016) included traditional healer- and Elder-led Sweat Lodge ceremonies, drumming, sharing circles and other cultural activities. In Reeves and Stewart’s (2014) study, Elders acted as advisors for the development of the intervention. Additional culturally rooted intervention characteristics included use of the Medicine Wheel (Gone 2009, 2011; Linklater, 2011; Marsh et al., 2016, 2018; Shrigley, 2019; Thomas & Bellefeuille, 2006), healing circles or group therapy (Gone, 2009, 2011; Heilbron & Guttman, 2000; Marsh et al., 2016, 2018; Reeves & Stewart, 2014; Shrigley, 2019; Thomas et al., 2013; Thomas & Bellefeuille, 2006), Sweat Lodge ceremonies (Gone, 2009, 2011; Marsh et al., 2016, 2018), smudging and use of traditional medicines (Gone 2009, 2011; Heilbron & Guttman, 2000; Linklater, 2011; Marsh et al., 2016, 2018; Reeves & Stewart, 2017; Shrigley, 2019; Thomas et al., 2013), and a holistic approach (Gone 2009, 2011; Linklater, 2011; Marsh et al., 2016, 2018; Reeves & Stewart, 2017; Shrigley, 2019; Thomas & Bellefeuille, 2006; Thomas et al., 2013). Psychoeducation related to trauma, addictions, and colonization was another intervention characteristic (Gone, 2009, 2001; Marsh et al., 2016, 2018), as well as the “talking cure” approach of verbally sharing personal traumatic experiences to a counsellor or in a group (Gone, 2009, 2011; Heilbron & Guttman, 2000; Linklater, 2011; Marsh et al., 2016; Reeves & Stewart, 2017; Thomas & Bellefeuille, 2006). Outcomes Reported All studies reported that participants experienced a strengthening of their Indigenous identity as a result of the interventions, which were central to healing. A key to culturally appropriate trauma interventions for participants was an increased understanding of historical trauma alongside an improved sense of personal empowerment and self-determination (Gone 2009, 2011; Linklater 2011; Marsh et al., 2016, 2018; Reeves & Stewart, 2017; Shrigley, 2019). Connection to spirituality was identified as a key aspect of an interventions’ effectiveness (Linklater, 2011; Reeves & Stewart 2016; Shrigley, 2019; Thomas & Bellefeuille, 2006). The collective aspect of interventions—healing circles and relationships with counsellors, traditional healers, and other clients—helped participants develop trust (Heilbron & Guttman, 2000; Marsh et al., 2018; Shrigley, 2019; Thomas & Bellefeuille, 2006). Participants reported that an outcome of interventions used was regaining trust in themselves and in connection to others 17 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 (Marsh et al., 2018). The trauma experienced by participants was described as a colonial wound and was expressed in terms of loss (Reeves & Stewart, 2017), which emphasized the depth of the emotional burdens that Survivors carry (Gone, 2011). Shrigley (2019) noted the complexity of healing from intergenerational trauma and Gone (2011) identified that interventions were a part of lifelong processes of healing from trauma. Throughout the studies examined, individual healing was embedded in community healing, and holistic approaches addressed the interconnectedness of human beings with each other, all living things, and the land. Research Design The majority of the studies utilized qualitative methodologies, and two studies (Marsh et al., 2016; Thomas et al., 2013) undertook a mixed methods approach. In-depth interviews, sharing circles, focus groups, and qualitative evaluations were employed to collect data. Indigenous methodologies highlighted the importance of guidance from Elders and Indigenous organizations, cultural ethics and Protocols, and the importance of storytelling as a research method (Linklater, 2011; Reeves & Stewart, 2014, 2017; Shrigley, 2019). More recent studies contextualized their research approach within decolonizing methodologies (Gone, 2009; Marsh et al., 2016, 2018; Reeves & Stewart, 2017; Shrigley, 2019). Reeves and Stewart (2017) described the decolonizing intent of their research as seeking “to honour Indigenous knowledges and epistemologies, promote community healing using Indigenous methods, and frame client mental health issues as belonging to larger structural inequities” (p. 35). Gone (2009) emphasized that the research’s “decolonization efforts” were “culturally grounded” and “community-based” (p. 760) and advocated for bridging evidenced-based practice with culturally sensitive approaches. Marsh et al. (2016, 2018) described their decolonizing approach in terms of its critical evaluation of methodology, ethics, and culturally acceptable practices. All studies involved collaboration with Indigenous organizations, located both on and off reserve. Researchers sought approval from the leadership of organizations with which they collaborated, Elders, and Band leaders. The interpretation of results across the studies involved thematic analysis conducted by researchers who identify as Indigenous (Linklater, 2011), non-Indigenous (Heilbron & Guttman, 2000; Shrigley 2019), or who did not identify their cultural background (Gone 2009, 2011; Marsh et al., 2016, 2018; Reeves & Stewart, 2014, 2017; Thomas & Bellefeuille, 2006; Thomas et al., 2013). Throughout all the studies examined, researchers were not a part of the communities in which the research was conducted. Discussion Strengths and Gaps in the Literature Base The purpose of this project was to examine current studies regarding culturally relevant trauma interventions for Indigenous Peoples in Canada. We identified 11 studies representing seven interventions utilized to treat trauma that highlighted the emerging research on this topic. The studies examined reflect local approaches to helping community members to heal from trauma. Interventions were embedded in Indigenous organizations and facilitated by Indigenous administrators, Elders, traditional healers, and Indigenous counsellors. Community protocols were followed both in implementing interventions and throughout the research process. Interventions were founded upon key aspects of Indigenous worldviews, namely holism, relationality, spirituality, and connection to the land. Considering the preponderance of interventions studied that were conducted in Ontario, there is a need 18 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10936 for research representing Indigenous communities from all parts of Canada. All interventions studied were conducted with adults. There remains a need for interventions and research to be conducted with children, youth, and families. Considering the intergenerational impacts of trauma and the collective, familial orientation of Indigenous worldviews, interventions with children, youth, and families represent a distinct gap. Participants reported a general improvement in symptoms related to trauma; however, small sample sizes, lack of comparison groups, and limited follow-up protocols may limit the generalizability of these findings. More recent studies identified their research as using Indigenous and decolonizing methodologies. In keeping with these methodologies, authors described their commitment to conducting research that benefits participating communities. Qualitative or mixed methods approaches that utilized storytelling with a relational focus aligned well with Indigenous worldviews. However, across studies, researchers external to the communities in which the research was grounded were responsible for the interpretation of results, typically through thematic analysis, highlighting a potential weakness in research using Indigenous and decolonizing methodologies. Despite the rigour visible in the research approaches used, there is opportunity to explicate and articulate what is meant by Indigenous methodologies and decolonizing methodologies, particularly by authors claiming to use these approaches, and to use participatory approaches that allow the participants have power and voice throughout the research process, including during data analysis. Recommended Future Directions Given the mental health burdens experienced by Indigenous Peoples due to higher rates of PTSD and lack of adequate mental health care (McIntyre et al., 2017), there is an urgent need to expand trauma services within Indigenous communities. These services should be based on research establishing their therapeutic effectiveness. Indigenous communities are requesting interventions that are culturally adapted or grounded. They also have called for the resources to conduct their own research in order to better facilitate community healing (Adelson, 2005; Stewart & Marshall, 2017). In particular, interventions developed for children, youth, and families are needed, as well as interventions that are tailored to a diverse range of Indigenous groups and cultures. Morrissette and Goodwill (2013) provided recommendations about stages of intervention to assist Indian Residential School Survivors during the formal disclosure process as part of the TRC; these recommendations may be useful when considering future interventions. Survivor engagement and validation highlights the need for empathic listening by therapists, consideration of potential impacts of the intervention on significant others, and recognition of diversity across Indigenous groups. Therapeutic socialization and intervention clarification entail a collaborative therapeutic stance in which therapists are transparent in their role. Finally, abuse identification and clarification assist Survivors in articulating their experience of abuse and its meaning in their lives. These recommendations may be beneficial to the future implementation of trauma interventions within Indigenous communities in Canada. Limitations The small number of trauma intervention studies identified in this review allowed for a discussion of the approaches to trauma intervention research but not an evaluation of the efficacy or effectiveness of these interventions. There were limitations regarding the search strategy used. Despite efforts to identify all 19 Panofsky et al.: Indigenous Trauma Intervention Research in Canada Published by Scholarship@Western, 2021 published empirical studies of trauma interventions within Indigenous communities in Canada, some studies may have been missed due to search term limitations. The inclusion of “peer-reviewed empirical articles” could overlook studies with Indigenous communities who may be implementing their own trauma interventions but not publishing the findings in scholarly journals. Thus, expanding the search criteria to include grey literature related to community-based trauma interventions could offer additional insight pertaining to how Indigenous communities are conducting their own research. Conclusion This narrative literature review explored culturally relevant interventions that addressed psychological trauma with Indigenous populations by identifying 11 studies representing seven interventions. This study highlighted the distinct Canadian context and identified a need to fill gaps in the literature with research that is collaborative, community-based, and elaborates on the link between cultural continuity and positive health outcomes (Adelson, 2005; Bombay et al., 2009; Chandler & Lalonde, 2008; Stewart & Marshall, 2017). The studies examined reflect local approaches to helping community members heal from trauma, wherein interventions were embedded in Indigenous organizations, facilitated by Indigenous Peoples, and founded upon Indigenous worldviews. There is a need for additional research representing the diversity of Indigenous Peoples and communities across Canada and for interventions and research to be conducted with children, youth, and families. The use of Indigenous and decolonizing methodologies is a positive direction that is a foundational part of recent studies. 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