Health and Well-Being: Historical,Present and Future Challenges for Indigenous and Non-Indigenous Peoples by Holly Graham

1. May 5, 2019 PAS Conference: Change, Growth,
Strength
Health and Wellness: Historical, Present, and Future
Challenges for Indigenous and non-Indigenous
peoples
Holly Graham
RN, PhD, R. D. Psychologist
Assistant Professor, College of Nursing, University of Saskatchewan

2. Outline: Historical, Present, and Future Challenges for Indigenous and non-
Indigenous peoples
Your questions/concerns?
Challenges
Adverse Childhood Experiences (ACE)
History
Indigenous /colonization/PTSD
Trauma
Present Indigenous Health
Resilience
Trauma Informed Principles (TIP)
and implication for practice
Now what?
Personal journey along professional
journey
Truth & Reconciliation: Calls to
Action

3. Challenges
Sociopolitical history between Indigenous & non-Indigenous peoples in
Canada (colonization)
Important to understand how current disparities have evolved & accurate
account of relationship
Provide alternative point of view for existing observations or experiences
Avoid “victim blaming”, perpetuation of negative stereotypes
All Canadians require an accurate account of the colonial relationship
Similar experiences for Indigenous peoples globally
Present – willimpact the future

4. PAST
Impacts the PRESENT

5. Trauma
= “experiences that overwhelm an individual’s capacity to cope” (p. 6)
 Single incident trauma: accident, natural disaster, witness violence
 Complex or repetitive trauma: ongoing abuse, domestic violence, ongoing betrayal, trapped
emotionally or physically
 Developmental trauma: early exposure (infants & youth); neglect, abandonment; physical or sexual
abuse; witness violence/death; interferes with healthy attachment & development
 Intergenerational trauma: psychological/emotional effects that can be experienced by people who
live with trauma survivors; coping/adapting patterns can be passed down
 Historical trauma: cumulative emotional/psychological wounding over the lifespan & across
generations emanating from massive group trauma. Examples: genocide, colonialism, slavery, and
war
Trauma-Informed Practice Guide, May 2013, p. 6

6. Incidence of Trauma
Common
76% of Canadian adults report some type of trauma exposure;
9.2 % meet the criteria for PTSD
Estimated 50% of all Canadian women and 33% of Canadian men have
survived at least one incidence of sexual or physical abuse
Trauma & potential for misdiagnosis (p. 11)
Trauma-Informed Practice Guide, May 2013

7. 1995-1997 Adverse Childhood
Experiences (ACE)
https://www.samhsa.gov/capt/sites/default/files/images/adverse-childhood-experiences-pyramid-lg.jpg

8. Adverse Childhood Experiences (ACE)
Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Intimate partner violence
Mother treated violently
Substance misuse within
household
Household mental illness
Parental separation or
divorce
Incarcerated household
member

9. ACE Score: Prior to your 18th Birthday
 Did a parent or other adult in the household often or very often… Swear at you, insult you,
put you down, or humiliate you? or Act in a way that made you afraid that you might be
physically hurt?
No___If Yes, enter 1 __
 Did a parent or other adult in the household often or very often… Push, grab, slap, or throw
something at you? or Ever hit you so hard that you had marks or were injured?
No___If Yes, enter 1 __
 Did an adult or person at least 5 years older than you ever… Touch or fondle you or have
you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal
intercourse with you?
No___If Yes, enter 1 __
https://www.ncjfcj.org/sites/default/files/Finding%20Your%20ACE%20Score.pdf

10. ACE Score: Prior to your 18th Birthday cont.:
 Did you often or very often feel that … No one in your family loved you or thought you were
important or special? or Your family didn’t look out for each other, feel close to each other, or
support each other?
No___If Yes, enter 1 __
 Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty
clothes, and had no one to protect you? or Your parents were too drunk or high to take care
of you or take you to the doctor if you needed it?
No___If Yes, enter 1 __
 Were your parents ever separated or divorced?
No___If Yes, enter 1 __

11. ACE Score: Prior to your 18th Birthday cont.:
 Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or
Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
No___If Yes, enter 1 __
 Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No___If Yes, enter 1 __
 Was a household member depressed or mentally ill, or did a household member attempt
suicide? No___If Yes, enter 1 __
 Did a household member go to prison?
No___If Yes, enter 1 __

12. Adverse Childhood Experiences (ACE)
1995-1997
N= 17,000 participants
Found:
ACEs are common: 28% physical abuse; 21% sexual abuse
ACEs cluster: almost 40% reported ≥2 ACEs; 12.5% experienced ≥4
ACEs have a dose-response relationship with many health problems
(numerous health, social, and behavioral problems throughout lifespan,
including substance use disorders)
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss,
M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction
to many of the leading causes of death in adults: The adverse childhood experiences
(ACE) study. American Journal of Preventative Medicine, 14(4), 245-258.

13. ACE Score: What does it mean?
stunning link between childhood trauma and the chronic diseases
people develop as adults, as well as social and emotional
problems. This includes heart disease, lung cancer, diabetes and many
autoimmune diseases, as well as depression, violence, being a victim of
violence, and suicide.
As your ACE score increases, so does the risk of disease, social and
emotional problems. With an ACE score of 4 or more, things start getting
serious. The likelihood of chronic pulmonary lung disease increases 390
percent; hepatitis, 240 percent; depression 460 percent; attempted
suicide, 1,220 percent.

14. ACEs: Suicide
Suicide attempts. ACEs in any category increased the risk of
attempted suicide by 2- to 5-fold throughout a person’s lifespan,
according to a 2001. According to a recent 2017 article, individuals who
reported 6 or more ACEs had 24.36 times increased odds of attempting
suicide.
https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-
experiences

15. Indigenous Peoples

16. History of Relationship between Indigenous and non-
Indigenous Peoples
Colonization
Epidemics
Residential Schools
Indian Act

17. Colonization
“Disastrous for Native culture, identity and pride” (Lee, 1992, p. 211)
Multiple layers: physical, economic, cultural, social, and psychological
(Wesley-Esquimaux & Smolewski, 2004)
Epidemics; residential schools (1863-1996); Indian Act
Dis-connection- Connection

18. Epidemics
Severe social disorganization
Traditional social structures, alliances and kinship ties – disrupted
Confidence in traditional leaders and healers - undermined
Aftermath of war and disease lost hope - social disintegration followed
Estimated 90 to 95 % - Indigenous population died within two
generations of contact in 1492

19. Residential Schools (1883-1996 in SK)
“We Were Children”
 https://www.youtube.com/watch?v=9daBqAddI_s
Partnership-Canadian government & churches
Purpose-assimilation
“Dis-connecting children physically, emotionally, mentally and
spiritually from their language, culture and their communities, from
their own sense of identity as being Indian”
(Chansonneuve, 2005, p. 44)

20. Exposure to Violence and a Child’s Developing Brain
http://www.youtube.com/watch?v=brVOYtNMmKk
Dr. Bruce Perry

21. Residential Schools: Long-term implications
Cultural denigration, humiliation and shaming were standard
practices in residential schools. This deprived the children of
self-esteem and, in many cases, led to life-long feelings of
self-hatred and depression
(Chansonneuve, 2005)
60’s Scoop …

22. Indian Act 1876
a colonist relationship
created to guide Canada’s relations with First Nations peoples by
imposing several restrictions on them in order to meet two mail goals:
to “civilize” the First Nations people and to “assimilate” them into
Canadian society
(Office of the Treaty Commissioner, 2008)

23. Indigenous Responses to Colonization:
Historic Trauma
Intergenerational Trauma – history of loss and trauma
Disconnection
PTSD
Increased health & mental health challenges

24. Historic Trauma
“Unremitting personal and collective trauma due to demographic collapse,
resulting from early influenza and smallpox epidemics and other infectious
diseases, conquest, warfare, slavery, colonization, proselytization, famine and
starvation, the 1892 to the late 1960s residential school period and forced
assimilation”
(Wesley-Esquimaux & Smolewski, 2004, p. 1)

25. Intergenerational/ Multigenerational Grief
“Generational or multi-generational trauma happens when the effects of trauma are not
resolved in one generation. When trauma is ignored and there is no support for dealing
with it, the trauma will be passed from one generation to the next. What we learn to see
as “normal”, when we are children, we pass on to our own children. Children who learn
that physical and sexual abuse is “normal”, and who have never dealt with the feelings
that come from this, may inflict physical abuse and sexual abuse on their own children.
The unhealthy ways of behaving that people use to protect themselves can be passed on
to children, without them even knowing they are doing so”
(Aboriginal Healing Foundation, 1999)

26. PTSR vs PTSD
Post Traumatic Stress Response (PTSR) vs Post Traumatic Stress Disorder
(PTSD)
“Normalizing their response versus pathologizing their current state”
(Mitchell & Maracle, 20005, p.18)

27. Internalized Oppression
“systematic subjugation of a group of people by another group of
people with access to social power, the result of which benefits one
group over the other and is maintained by social beliefs and practices.
Because oppression is institutionalized in society, target group
members often believe the messages and internalize the
oppression…when believe the stereotypes they are taught about
themselves…tend to act them out…perpetuate…reinforces the
prejudice”
(Mussell, 2005, p. 16)

28. Aboriginal Healing foundation: Research Series
http://www.ahf.ca/publications/research-series

29. Physiology of Trauma
HPAAxis

31. The Survivors Speak: A Report of the Truth and
Reconciliation Commission of Canada
Medical Attention “ we never saw anybody” (p. 177); “ sick had to tough it out”; “no
anaesthesia, used ordinary pliers”;
Hospitalization –sanatorium often confined to their beds
9 years old, caught leaving her room, nun put her in the operating room, left in total
darkness, thinking about what they would do to her when they returned. When they
returned to her room, they tied her hands and feet to the bedpost
Students who were hospitalized sometimes never returned; One student shared she
held a little girl while she passed away in her arms…
 hearing loss (p. 142); Group punishment (p. 144);
“electric chair” (p. 143), after buckled into the chair an electric current from a hand-
cranked generator was run through their bodies

32. The Survivors Speak: A Report of the Truth and
Reconciliation Commission of Canada cont.
“sometimes we had to kneel all day”
“whatever we dropped there we have to eat it or lick it”
“ I saw a nun push a girl down a flight of stairs, she never got up…when
she came back she was kind of crippled. She was never the same after
that”
“ when he couldn’t make me cry, or weaken me that way, he would get all
the students to call me all different kinds of names, and laugh at me,
forcibly make them laugh at me so that I cried, and I cried every single
time when it happened”

33. Medicine Unbundled
 Last segregated Indian Hospital closed 1996 Fort Qu’Appelle, SK
 Separate system aprox. 20 hospitals ( 15 West. Canada); 1 SK
 Apprehension of sick Indigenous people was made legal by the Indian Act; not having achieved the status of “persons”,
susceptible to quarantine or incarceration at the whim of doctors, Indian agents, or government officials; Declaring
individuals contagious was a good means of control
 “We cannot mature as a nation if we insist on living a lie or a half-truth. We need to rewrite our history, accept responsibility,
and make sure it never happens again, which means acknowledging the dark or shadow-side of our past and present
 Experimental bodies (p. 62): nutritional experiments (6 schools) & deliberate starvation; families unaware, results published
by Canadian Medical Association; First released by Health Canada April 26, 2000
 Dr. Dorothy Sam Williams, Chief of Medical Staff, West Coast General Hospital – “suggests that hunger, nutritional
experiments, and other residential school experiences were contributors to abnormal First Nations relationships with food
and can be linked to metabolic disorders – hypoglycemia, types 2 diabetes, high blood pressure, and stroke” (p. 66)

35. Segregated health care
 )
1920s-1980s
Operated at half the cost of provincial hospital (p. 14)

37. PRESENT

38. Indigenous Health & Wellness
Indigenous peoples do not have the same level of health and well-being
as other Canadians
Indigenous peoples have the same basic needs as other peoples,
however, there are additional challenges that are multifaceted and stem
from colonization
Mental health issues have been long overlooked, especially in First
Nation communities
How does this impact you as the Health Care Provider?

39. Healing
All levels of government, social change (All Canadians), and individual
perseverance
Determinants of Health
Income & social status; social support networks; education and
literacy, employment and working conditions, social environments,
physical environments, personal health practices and coping skills;
healthy child development (HCD); biology and genetic endowment,
health services, gender, and culture.
http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php

40. Grade 12 Graduation Rates
High school graduations in the province (SK) have stalled,
despite the government’s lofty goal of an 85-per-cent
graduation rate by 2020.
In 2013, graduation rates were 74.8 per cent overall, but a
dismal 37.4 per cent for self-declared First Nations and
Metis students.
http://leaderpost.com/news/politics/saskatchewan-graduation-rates-stall

41. Personal Healing
 Processing and coming to terms with the
traumatic/overwhelming experience; controlling and mastering
the stress reactions (physiological and biological); and re-
establishing secure social connections and inter-personal
efficacy
 Enhance Resilience
 Decolonization
 What does decolonization mean to you?

42. Future
Depends on the PRESENT

43. Supporting Indigenous Health & Wellness
Require accurate historical portrayal
of the relationship between
Indigenous & non-Indigenous
peoples in Canada
Creates an informed perspective
Self awareness & reflection
Insight into personal role (colonized or
colonizer)
Our perceptions influence our
interactions
Interpersonal communication
Practice cultural safety, Rogerian
principles (respect, positive regard, non-
judgmental)
Guiding Principles/Professional Code of
Ethics
Goal = successful engagement
RESPECTFUL
RELATIONSHIPS

44. Foundational Fundamental Knowledge for HCPs: Prior to Engagement
Understanding of colonization & continued impact on current mental health &
wellness (Kirmayer, Brass & Valaskakis, 2009) and neocolonial practices
(Smith, 1999)
Cross-cultural training – Indigenous worldviews, cultures, and traditions
(Calabrese, 2008)
Comprehension that all peoples’ mental health & well-being are impacted by
the SES (PHAC, 2010; Raphael, 2006)

45. Trauma-Informed Practice Guide, 2013
2011 – consultations with practitioners
May 2013 - TIP Project Team & Advisory Committee (BC)

46. Trauma Informed Practice (TIP)
Takes into consideration the prevalence of the many forms of
violence & trauma and the variation in how each individual
copes, and emphasizes the person’s safety, choice, and
control.
 http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf
Trauma-Informed Practice Guide, May 2013

47. Principles & Practice of Trauma-Informed Approaches (4)
1) Trauma awareness
Trauma central to development; range of adaptations; relationship with substance
use/physical health/mental health
2) Emphasis on safety & trustworthiness
Often feel unsafe; Often experienced abuse of power in important relationships;
Currently living in unsafe relationships or living situations
Mitigate: welcoming intake, clear information about programming; ensuring informed
consent; create crisis plans; demonstrate predictable expectations; and scheduling
appointments consistently

48. Principles & Practice of Trauma-Informed Approaches cont.
3) Opportunity for choice, collaborative, and connection
Environments: foster efficacy, self-determination, dignity & personal control,
opportunity to establish safe connections – with treatment providers, families,
peers, and the wider community
Staff: communicate openly, equalize power, allow expression of feelings
without fear of judgement, provide choices for treatment preferences, work
collaboratively with clients

49. Principles & Practice of Trauma-Informed Approaches cont.
4) Strengths based & skill building
Clients assist to identify their strengths and to (further) develop
resiliency and coping skills
Practitioners: emphasize teaching & modeling skills for recognizing
triggers, calming, centering, and staying present
Trauma-Informed Practice Guide, May 2013

50. Safety & Needs of Practitioners
Safety & changes in treatment culture
Awareness of vicarious trauma & staff burnout
May be triggered by client responses & behaviors
Key elements of trauma-informed services:
Staff education
Clinical supervision
Policies & activities that support staff self-care
Trauma-Informed Practice Guide, May 2013, p. 13

52. Comments? Thoughts?
Dr. Holly Graham
RN, BA, BScN, MN, PhD, R.D. Psychologist
Assistant Professor, College of Nursing
University of Saskatchewan
holly.graham@usask.ca
306 966 6237