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First Nations and Inuit Health

First Nations Mental Wellness Continuum Framework - Summary Report

December 2014
Health Canada and Assembly of First Nations

Introduction

Mental health and substance use issues continue to be a priority concern for many First Nations communities. While there are different kinds of specific mental health issues that can affect communities, mental wellness is a broader term that can be defined as a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, and is able to make a contribution to her or his own community.

Mental wellness is supported by culture, language, Elders, families, and creation, and is necessary for healthy individual, community and family life. First Nations embrace the achievement of whole health - physical, mental, emotional, spiritual, social, and economic well-being - through a coordinated, comprehensive approach that respects, values, and utilizes First Nations cultural knowledge, approaches, languages, and ways of knowing.

Federal, provincial, and territorial mental wellness programs and services seek to address the indicators that challenge wellness in many First Nations communities; however, there are gaps in services. Further, programs and services are not always delivered in a culturally safe manner.á As a result, First Nations communities and leadership have been calling for the development of a coordinated, comprehensive approach to mental health and addictions programming.á In response, the First Nations and Inuit Health Branch (FNIHB), the Assembly of First Nations (AFN), and Indigenous mental health leaders from various First Nations non-government organizations jointly developed the First Nations Mental Wellness Continuum Framework (the Framework).

Mental wellness is a balance of the mental, physical, spiritual, and emotional. This balance is enriched as individuals have: purpose in their daily lives whether it is through education, employment, care giving activities, or cultural ways of being and doing; hope for their future and those of their families that is grounded in a sense of identity, unique indigenous values, and having a belief in spirit; a sense of belonging and connectedness within their families, to community, and to culture; and finally a sense of meaning and an understanding of how their lives and those of their families and communities are part of creation and a rich history.

Culture

The cultural values, sacred knowledge, language, and practices of First Nations are essential determinants of individual, family, and community health and wellness. Despite the impacts of colonization, many First Nations people have maintained their cultural knowledge in their ways of living (with the land and with each other) and in their language. These foundations have ensured First Nations people have strength, laughter, and resilience. Cultural knowledge about mental wellness does not narrowly focus on "deficits". Rather, it is grounded in strengths and resilience. Culture is the foundation for a "good life", and the knowledge contained within culture applies across the life span and addresses all aspects of life.

First Nation languages, culture, and teachings are tied to the past, the present, and the future - they are the stepping stones to a brighter tomorrow. First Nations individuals, families, and communities have a wealth of knowledge from which to draw to know how to live in balance, to care for themselves and others, and to restore balance when it is lost.

Model and Continuum of Mental Wellness Services

The First Nations Mental Wellness Continuum (the Continuum) is a complex model, rooted in culture and comprised of several layers and elements foundational to supporting First Nations mental wellness. Embedded within the model are the key themes that emerged through dialogue with partners as well as the social determinants of health that are critical to supporting and maintaining wellness. The Continuum must be supported by a number of partners at several levels, such as:

  • Communities
  • Nations
  • Regional Entities
  • the Federal Government,
  • Provincial and Territorial Governments,
  • Non-government Organizations, and
  • Private Industry.

The model also includes a number of elements that support the health system, specifically: governance, research, workforce development, change áand risk management, self-determination, and performance measurement.

The Continuum aims to support all individuals across the lifespan, including those with multiple and complex needs. The centre of the model refers to the interconnection between mental, physical, spiritual, and emotional behaviour - purpose, hope, meaning, and belonging.á A balance between all of these elements leads to optimal mental wellness.

Figure 1: First Nations Mental Wellness Continuum Model

Continuum Model

Figure 1: Continuum Model

Legend: (from centre to outer ring)

  • Four Directions (outcomes) - Hope; Belonging; Meaning; and Purpose.
  • Community - Kinship; Clan; Elders; and Community.
  • Populations - Infants and Children; Youth; Adults; Gender-Men, Fathers and Grandfathers; Gender-Women, Mothers and Grandmothers; Health Care Providers; Community Workers; Seniors; Two-Spirit People and LGBTQ; Families and Communities; Remote and Isolated Communities; Northern Communities; and Individuals in Transition and Away from Reserve.
  • Specific Population Needs - Intergenerational Impacts of Colonization and Assimilation; People Involved with Care Systems and Institutional Systems; Individuals with Process Addictions; Individuals with Communicable and Chronic Diseases; Individuals with Co-occurring Mental Health and Addictions Issues; Individuals with Acute Mental Health Concerns; Crisis; and People with Unique Needs.
  • Continuum of Essential Services - Health Promotion, Prevention, Community Development and Education; Early Identification and Intervention; Crisis Response; Coordination of Care and Care Planning; Detox; Trauma-informed Treatment; and Support and Aftercare.
  • Supporting Elements - Performance Measurement; Governance; Research; Education; Workforce Development; Change Management and Risk Management; and Self-Determination.
  • Partners in Implementation - Non-governmental Organizations; Provincial and Territorial Government; Federal Government; Regional Entities; Nations; Communities; and Private Industry.
  • Indigenous Social Determinants of Health - Environmental Stewardship; Social Services; Justice; Education and Lifelong Learning; Language Heritage and Culture; Urban and Rural; Land and Resources; Economic Development; Employment; Health Care; and Housing.
  • Key Themes for Mental Wellness - Community Development, Ownership and Capacity Building; Quality Care System and Competent Service Delivery; Collaboration with Partners; and Enhanced Flexible Funding.
  • Culture as Foundation - Elders, Cultural Practitioners and Kinship Relationships; Language, Practices, Ceremonies, Knowledge, Land and Values.

Continuum of Essential Services

A full spectrum of culturally competent supports and services is necessary to support mental wellness. áThis continuum includes:

  • Health Promotion, Prevention, Community Development, and Education
  • Early Identification and Intervention
  • Crisis Response
  • Coordination of Care and Care Planning
  • Detox
  • Trauma-Informed Treatment
  • Support and Aftercare

It is recognised that not all of the services described above will be available in every community; but, through collaboration and comprehensive planning, all communities can have access to key services. By identifying the key services, it is possible to identify gaps and avoid duplicating services that are already available within the community, an adjacent community, or from the provincial or territorial governments.

Key Themes

During regional discussion sessions, the National Gathering, the federal discussion, and the National Validation and Implementation Session, several key themes emerged that have shaped the Framework and the Continuum.á These themes are:

  • Culture as Foundation
  • Community Development, Ownership, and Capacity Building
  • Quality Care System and Competent Service Delivery
  • Collaboration with Partners
  • Enhanced Flexible Funding

A list of Implementation Opportunities has been created which will provide guidance to communities and partners at the community, regional, provincial, territorial, federal, and national level on concrete strategies and activities for each theme. áThis evergreen document will be continually updated as progress is made towards completion of implementation opportunities and as new opportunities emerge.

Theme 1: Culture as Foundation

First Nations leadership, youth, community members, and Elders have made it clear that culture must be at the centre of mental wellness. Culture must not only guide our work, it must be understood as an important social determinant of health. Culturally specific interventions are holistic; they attend to the spirit, mind, body, and emotions simultaneously. Culture as a foundation implies that all health services and programs related to First Nations go above and beyond creating culturally relevant programs and safe practices. As such, culture as a foundation means starting from the point of Indigenous knowledge and culture and then integrating current policies, strategies, and frameworks.

Priorities for Action:

  • Responding to the Diversity of First Nations Communities
  • Defining Culture
  • Valuing Cultural Competency, Cultural Safety and Indigenous Knowledge
  • Understanding the Role of Language in Mental Wellness

Theme 2: áCommunity Development, Ownership and Capacity Building

Community development, ownership, and capacity building are significant factors which must be taken into account in enhancing First Nations mental wellness. For example, community experience and research have demonstrated the positive impact that community ownership of local programs and infrastructure can have on First Nations mental wellness.á Community development, ownership, and capacity building will play a key role in ensuring that the continuum of mental wellness programs and services for First Nations are relevant, effective, and meet community needs.

Priorities for Action:

  • First Nations Control of Services
  • Building on Community Priorities
  • Developing Community Wellness Plans
  • Working Together in Partnership
  • Investing in Community
  • Development and Capacity Building

Theme 3: Quality Care System and Competent Service Delivery

Mental Wellness depends on access to a full spectrum of culturally competent supports and services.á It is essential that the continuum of services be located within a quality care system and that the services and supports be of high quality and culturally competent. First Nations organzations, provincial, territorial, and federal governments, and other key partners will need to work together to achieve this standard. It also requires attention to the key elements that support a quality care system, such as performance measurement, governance, and workforce development.

Priorities for Action:

  • Delivering Accessible Services
  • Providing Quality Mental Wellness Programs and Services
  • Responsiveness, Flexibility, Reliability
  • Proactive Planning and Crisis Supports and Services
  • Delivering Trauma-Informed Care
  • Promoting and Recognizing a Culturally Competent Workforce
  • Providing Education, Training and Professional Development
  • Supporting Worker Wellness

Theme 4: Collaboration with Partners

Enhancing First Nations mental wellness requires strategic action that goes beyond the mandate of the First Nations and Inuit Health Branch. It involves other federal government departments, provincial and territorial governments, and First Nations communities and requires supports and services that cross the health, justice, employment, and social service sectors. These partners must working collaboratively and cooperatively to ensure that a coordinated, comprehensive continuum of mental wellness services is available to those who require it. Currently, although it is recognized that there are shared roles and responsibilities, these roles and responsibilities are not always clear.

Priorities for Action:

  • Defining Clear Roles and Responsibilities
  • Establishing Leadership
  • Creating Partnerships and Networking
  • Developing System Navigators, and Case Managers
  • Providing Advocacy
  • Raising Awareness-Reduction of Stigma and Protection of Privacy

Theme 5: Enhanced Flexible Funding

Funding alone isn't sufficient to ensure a coordinated, comprehensive approach to mental wellness; however, participants in the various engagement sessions communicated that additional funding and the flexibility and permanency of current funding are critical factors. The lack of adequate and sustainable funding and the continuous focus on project funding were identified by participants in regional and national discussions as harmful to mental wellness. Currently, funding and decision-making that affect First Nations are siloed within multiple federal, provincial, and territorial departments, making it challenging to address the determinants of health and to develop comprehensive approaches to mental wellness.

Priorities for Action:

  • Providing Additional Funding
  • Moving Away from Time-Limited and Siloed Funding
  • Increasing Flexibility of Funding

Moving Forward

A strength of the Framework process has been its connection to a wide range of regional and national First Nation health and wellness networks, which have guided the process, shaped the Framework's vision, and supported engagement with First Nations communities. Specific direction for the implementation of the Framework has been developed in collaboration with key partners who will continue to refine ideas throughout implementation.

The Framework process has helped to develop a commitment to a shared vision for mental wellness. For successful implementation, key stakeholders must take action within their existing resources and collaborate with other partners. Achieving the envisioned mental wellness continuum will require sustained commitment, collaboration, and partnerships, supported by effective leadership across the system. "Change leaders", whether individuals or collectives (partners, teams, institutions, agencies, families, or communities), will play a key role. áMomentum is building in several regions across the country.á Stronger partnerships are being developed and gaps are beginning to close in meeting the mental wellness needs of First Nations.

The Framework will guide communities to better plan, implement, and coordinate comprehensive responses to the full range of mental wellness challenges in a manner consistent with community priorities. It outlines how communities can adapt, optimize, and realign their mental wellness programs and services to achieve a comprehensive continuum of quality programs and services. In addition, the Framework will support communities to use existing funding in a more holistic way, informed by the essential continuum of services and recognizing the impact of the determinants of health on mental wellness.

The Framework will support conversations with major healthcare providers, other service providers, and jurisdictional partners to enhance collaboration and build partnerships to ensure the needs of First Nations people are met. Strategic implementation of the Continuum depends on making the most of relationships with and among provincial, territorial, and federal government departments. The Framework supports a shift away from programming that doesn't communicate or work effectively together toward a comprehensive mental wellness system for First Nations that is based on an evidence-based continuum of care. It provides guidance for system-level changes in the short, medium, and long term (e.g., redesigning existing programs, re-profiling existing resources, and integrating resources across jurisdictions) that are grounded in First Nations community priorities and informed by regional, provincial, territorial, and federal government priorities. Further, the Framework will guide new investments as opportunities arise.

Changes over time will need to be tracked and measured to know what progress has been made and where more resources and efforts are needed to fully achieve the shared goal of providing comprehensive, culturally relevant, and culturally safe community-based services to First Nations individuals, families, and communities. Monitoring progress toward achieving system change can be accomplished through the development of program and service delivery standards and indicators. Standards and indicators can, for example, provide concrete parameters for consistent quality services which align with provincial and territorial systems.

Conclusion

The First Nations Mental Wellness Continuum Framework, developed through intensive collaboration between First Nations partners and Health Canada's First Nations and Inuit Health Branch, represents a shared vision wherein First Nations individuals, families, and communities across Canada are supported to enjoy high levels of mental wellness. Achieving this vision will require:

  • Culturally-grounded community development and capacity building that reduces risk factors and increases protective factors;
  • Comprehensive, coordinated, high quality, culturally responsive mental wellness programs and services for First Nations people living on reserve; and
  • Sustained commitment and collaboration of many First Nations, federal, provincial, and territorial partners supported by strong leadership and flexible funding.

Recognizing that a roadmap is needed to help guide and coordinate community, regional, and national action, the partners have collaborated on an evergreen Implementation Plan to accompany and put into practice the Framework. The Implementation Plan identifies urgent and actionable implementation priorities for the short, medium, and long term. It is expected that the list of priorities will change over time as new issues and opportunities emerge. As First Nations health organizations and federal and provincial governments develop workplans and as First Nations develop community wellness plans, the Continuum, the Framework and the Implementation Plan can serve as important resources.

An important next step will be the development of an evaluation plan that will support ongoing improvement in the implementation processes as the partners work towards the envisioned continuum of mental wellness services.