Sarah J. Ponton*, Mikaela D. Gabriel*, Jay Lu*, Suzanne L. Stewart*, Roy Strebel*, Sabina Mirza*
ABSTRACT
Indigenous Peoples face significant disparities related to mental health and well-being due to colonization and its ongoing impacts, further impacted by COVID-19. Following Arksey and O’Malley’s six-stage framework and Bartlett’s Indigenous Two-Eyed Seeing approach, a reflexive review of the literature about Indigenous mental health during the pandemic was undertaken. Consultant interviews were also completed, and thematically organized, with Indigenous People from three Indigenous-serving mental health organizations in Ontario. Key themes included: highlighting Indigenous voices, historical context, challenges and strengths in culturally based services, virtual transition, financial support for Indigenous services, health service delivery and well-being, and culture and community connection. The themes bridge gaps in service provision, the mental health impacts of loss of connection with community due to pandemic restrictions, how mental health supports can be improved, and which services provided during the pandemic should continue. This review provides service providers clear recommendations based on the findings to help improve Indigenous mental health and service provision.
Key Words Indigenous wellness; mental health; service provision; Two-Eyed Seeing; COVID-19 pandemic; scoping review.
Achieving mental health and holistic healing is an urgent problem for Indigenous Peoples in Canada. Indigenous Peoples have disproportionately experienced health risks and inequities due to colonization (Allen et al., 2020; Fish, 2019; Mehl-Madrona, 2019), further exacerbated by the COVID-19 pandemic (United Nations, 2021). To advance Indigenous health and wellness, healthcare systems must address the pervasive, systemic barriers that impact the health of Indigenous Peoples. Shkaakaamikwe gchi twaa miigwewin (Mother Earth’s Gifts) is a national research network for ending Indigenous illness through promotion of Indigenous mental health and healing. Through academic and community partnerships in 20+ sites across Canada (i.e., Ontario, Saskatchewan, Alberta, British Columbia) and international Indigenous communities (i.e., Hawai’i, Australia). These partnerships support a national shift from Western, biomedical-based, crisis-focused models, which perpetuates Indigenous mental illness and unbalance through limited-term interventions and supports.
The goal of this scoping review is to provide an overview of the emerging literature of Indigenous mental health during the COVID-19 pandemic, identify existing gaps, and inform recommendations on how to improve culture-based services during the COVID-19 and potential future pandemics. To meaningfully address the lived realities of Indigenous communities, consultant interviews were conducted with key informants within the Indigenous community of Toronto to explore barriers of well-being, immediate needs, and existing supports contextualizing the provision of culture-based mental health services during the COVID-19 pandemic.
This scoping review follows the six-stage framework developed by Arksey and O’Malley (2005) that enables a comprehensive, reflexive review of literature on Indigenous well-being, providing an iterative, non-linear process. This method complements the Two-Eyed Seeing approach, which incorporates the strengths of both Indigenous and Western ways of knowing, supported by the Two-Eyed Seeing approach often employed in Indigenous-led, community-based research (Bartlett et al., 2012; Iwama et al., 2009).
A holistic approach to searching for literature inclusive of peer-reviewed academic articles and grey literature identified relevant literature, and the following databases were searched: (1) Ovid APA PsycInfo, (2) Ovid MEDLINE, (3) Ovid EMBASE, (4) Scopus, and (5) Google Search Engine. For each database, five search terms were used and were restricted by the publication years of 2020–2021 (see Appendix A for Search Terms).
Three inclusion criteria were used for this scoping review: (1) Literature should include a sample of Indigenous People, or be based around a discussion about Indigenous People, in or outside of Canada; (2) Literature was published between 2020 and early 2021; and (3) Literature should discuss overall mental health, experiences providing holistic mental health services during COVID-19. Nine included papers met the inclusion criteria. Based on the research questions, review of the identified articles, and consultant interviews, common themes were found (see Table I), as discussed later (see Results).
TABLE I Summary of papers and themes extracted
To contextualize these findings, three senior leadership Indigenous experts in providing culturally based mental health services for Indigenous People during the COVID-19 pandemic were consulted from three separate organizations based in Ontario (i.e., two Indigenous organizations, and one non-Indigenous organization that provides Indigenous mental health services). Each semi-structured narrative interview was approximately 30 minutes (see Appendix B for Interview Questions). Interviews were transcribed, anonymized, and coded from an Indigenous narrative methodology developed by Stewart (2008) to identify themes. Consultant insights informed the results and recommendations for providing mental health services for Indigenous People during the COVID-19 pandemic.
Four metathemes emerged from the scoping review: (1) highlighting Indigenous voices, (2) historical context, (3) challenges in providing culturally based services, and (4) strengths in providing culturally based services.
This theme included the recognition of authors’ identities; cultural affiliation; description of cultural involvement in navigating COVID-19 coping skills and protocols; and the need for cultural practices in navigating a global pandemic. Only two chosen articles were written by Indigenous authors (Ineese-Nash, 2020; Tanana, 2020), two were written by both Indigenous and non-Indigenous authors (Dudgeon et al., 2020; Usher et al., 2020), and the remaining articles were written by non-Indigenous authors. Upon review, stark differences emerged in terms of author orientation, disclosure of tribal affiliation and community identification, narrative voice, personal connection, and discussion of historical context (see Theme: historical context).
This theme supported the need for community and cultural factors to support mental health. Past research promoted Indigenous perspectives as community and culture, treatment (Brady, 1995; Dumont, 2014; Green, 2010; Rowan et al., 2014), and impact of cultural suppression with factors related to autonomous, sovereign Indigenous health management and approaches to wellness (Júnior et al., 2020). Dudgeon et al. (2020) described that Indigenous mental healthcare responses to COVID-19 must include Indigenous perspectives, viewpoints, cultural understanding, and historical factors and be trauma-informed. Walker et al. (2021) also expressed the importance of cultural factors to mental health; Indigenous perspectives in the construction and formation of these services; and the integration of Indigenous values into service delivery (i.e., strength-based; Indigenous responses and knowledge sharing).
Indigenous authors expressed how their tribal identity supported specific narrative approaches and methodologies in the reception and reflection of research and components. Urbatsch and Robledo (2020) described the ways in which Indigenous identity shaped the perspective of COVID-19, with consideration of historical factors that precipitated the severity of COVID-19 in Indigenous communities.
Non-Indigenous authors did not explicitly discuss the value of culture or community unless it was specifically mentioned by the Indigenous People who were interviewed in their articles. Authorship positionalities impact explorations of COVID-19 and existing disparities faced by Indigenous People, particularly the analysis of historical, social, and political factors that directly contribute to Indigenous domains of health and access to services.
Indigenous authors contextualized COVID-19 within the ongoing impacts of colonization on Indigenous health disparities and barriers to accessibility of services, as well as the depth and scope of governmental actions that have and continue to contribute to Indigenous health inequities and disparities in mental health service access and use (Arriagada et al., 2020; Júnior et al., 2020; Tanana, 2020); identifying the need for specialized services and training; and pre-pandemic indicators of service use and present service limitations that burdened health systems and their impact on existing mental health rates (Júnior et al., 2020; Wendt et al., 2021). Mental health symptoms connected to colonization include depression, untreated suicide ideation leading to suicide, and substance use (Chandler & Lalonde, 1998; Dudgeon et al., 2020; Ineese-Nash, 2020; Tanana, 2020; Wendt et al., 2021).
In the absence of Indigenous colonial and historical context, less emphasis was placed by authors on Indigenous culture, history, politics, service delivery, and systemic challenges to appropriate care. Wendt et al. (2021) described that telemedicine mental healthcare, specifically for substance use, was previously not approved for substance use treatment; however, this changed in COVID-19 providing improved accessibility of healthcare and support for substance use treatment in remote or smaller communities. This service was not deemed a necessity until COVID-19 left no further alternatives despite pre-existing needs for community members. Historic context offers important gaps to address systemic care barriers for communities.
While virtual connection was necessary for maintaining connection, pandemic protocols challenged Indigenous communities which are generally closer, interdependent, and value collective collaboration (Tanana, 2020). Pandemic protocols and ensuing isolation increased rates of substance use and severity of mental health issues (i.e., anxiety and depression) and noted a severe impact on the physical, mental, and emotional health of global Indigenous communities.
Across articles, Indigenous communities reported strengths in culturally based services to address mental health and addictions. Telehealth services provided increased accessibility to medication that supported opioid addiction treatment alongside traditional healing practices being offered online (Wendt et al., 2021). Hotlines and phone-supported services were found to be most beneficial for older, transitory community members.
The Navajo Nation of Arizona was heavily impacted by COVID-19, and challenged community hopelessness by promoting programs and messages of self-compassion, self-forgiveness, and providing community connection through virtual programs. Mental healthcare services were adapted for three virtual-based interventions: telehealth visits; virtual check-ins; and electronic-visits (e-visits), and this led to the creation of the Indian Health Service (Tanana, 2020).
Dudgeon et al. (2020) provided key insights into how the COVID-19 pandemic impacted the Aboriginal and Torres Strait Islander (ATSI) people and developed recommendations for their physical and mental healthcare. ATSI people were recognized as having been especially impacted by COVID-19 due to systemic and pervasive poverty, poor living conditions, and subsequent impacts to health, and telehealth was ensured for continuation of ATSI health services. Key recommendations from the report were the right to self-determination; creating a strong healthcare workforce; addressing cultural determinants of health, including digital and telehealth; appropriately supporting cultural needs in mental health; and acknowledging data sovereignty (Walker et al., 2021).
With regard to barriers, one of the most significant identified barriers was the lack of appropriate funding, noting the lack of specialized and culturally safe resources for Indigenous People and Indigenous youth (Ineese-Nash, 2020; Júnior et al., 2020; Tanana, 2020; Walker et al., 2021; Wendt et al., 2021), as well as the lack of services offered in other languages. Júnior et al. (2020) discussed that lockdown protocols reduced mental health services, placing a strain on the already overburdened mental healthcare system in Canada. Additional difficulties were in transitioning to virtual service (Tanana, 2020; Walker et al., 2021; Wendt et al., 2021), lack of access to technological devices and internet connection (Dudgeon et al., 2020; Ineese-Nash, 2020; Walker et al., 2021; Wendt et al., 2021), barriers to immediate healthcare interventions (Tanana, 2020), and privacy issues with using virtual mental healthcare (Wendt et al., 2021). Physical isolation of communities was also a barrier (Dudgeon et al., 2020; Júnior et al., 2020) and that isolation and loneliness were still challenges (Ineese-Nash, 2020; Tanana, 2020; Urbatsch & Robledo, 2020; Wendt et al., 2021).
Privacy issues and lack of funding intersected with systemic racism, colonialism, and historical and ongoing trauma that affect Indigenous People in Canada (Arriagada et al., 2020; Dudgeon et al., 2020; Tanana, 2020; Urbatsch & Robledo, 2020; Usher et al., 2020; Walker et al., 2021; Wendt et al., 2021). Due to the historical context of colonialism and lack of funding, Indigenous communities were more vulnerable to poverty, overcrowding, homelessness, and food insecurity; these were acute risk factors that increased vulnerability to COVID-19 because of reduced access to facilities and resources needed to follow public health guidelines (i.e., sanitizing one’s environment, inability to isolate). This led to a worsening of mental health over the course of the pandemic as people experienced fears, stress, anxiety, job loss and increased financial burden, and the loss of community members (Arriagada et al., 2020; Júnior et al., 2020; Urbatsch & Robledo, 2020; Walker et al., 2021; Wendt et al., 2021). Indigenous women (Arriagada et al., 2020), Elders (Tanana, 2020), and Indigenous youth (Walker et al., 2021) were identified as being particularly vulnerable to worsening mental health. While the need for mental healthcare dramatically increased over the course of the pandemic, yet the same factors which created conditions that worsened mental health for Indigenous People were also significant barriers to healthcare access and use.
The narrative thematic analysis identified three core metathemes from consultant interviews: (1) virtual transition, (2) financial support for Indigenous services, and (3) health service delivery and well-being (Table II).
TABLE II Across participant analysis: metathemes and themes
Participants described adapting virtual care delivery with the onset of COVID-19,
We needed a lot of investment in our information technology infrastructure to be able to facilitate so much remote programming … we invested several hundreds of thousands of dollars into our I.T. infrastructure … just in back-end infrastructure to be able to facilitate the work that was needed and that spans many, many different areas. (Consultant A, p. 4)
Technological investment was required for both community member engagement and staff’s remote access. Consultant B described receiving donations of cellphones and laptops,
We were giving them to women so they could stay connected so we could reach them, make sure they don’t slip through the cracks, and we can’t locate them. But also, for them to engage in programming … The laptops went to families a lot for the children, because now they’re at home … So, when your children have their own for their own uses, then moms have their own for their own uses and cell phones and connectivity. (Consultant B, p. 4)
Community Consultant C, working from the non-Indigenous organization, described needing to hire additional counsellors due to the increase in Indigenous service use, “from 2020, to ’21, we had a 109% increase in Indigenous service use” (Consultant C, p. 3). They noted that there was a 26% increase in mental health support live chat conversations from 2019; 59% increase for texting from 2019; and website usage had an increase of 153%, and remote hires “allowed us to hire more Indigenous People without requiring them to leave their communities” (Consultant C, pp. 3–4). There were accessibility and connectivity barriers in remote Indigenous communities, “a lot of communities are struggling … they don’t have the broadband to do that, so we have to deliver it to those communities in audio format. So increased connectivity is – would be incredibly helpful” (Consultant C, p. 5).
Online adaptation saw great change to community gathering centres and service delivery, something that was significantly impactful to Indigenous Peoples, “so Indigenous People are relationship people or circle people or face to face people. Right. And so not being able to do a lot of that has created the necessity to pivot and change a lot of the services that we do” (Consultant A, p. 2). Some virtual translations were challenging, “we have a whole suite of services of clinicians that are doing one-to-one, and group mental health supports with families, and … working with youth and younger kids. But we can’t really do like play based therapy and things like that. That doesn’t really work virtually” (Consultant A, p. 1). Despite such challenges, online services improved accessibility for Indigenous clients outside of the urban centre,
… people are accessing the programs and the services, the ceremonies, the healers from all over. And there are women who have expressed that they have nothing where they are. And more than ever, they needed ceremony or access to a healer just to have a session. (Consultant B, pp. 2–3)
Virtual expansion offered community connection despite protocols, “So we’re working really hard to offer as much programming as possible … just to offer up that sense that you still have, like, your sisters and your representation and that there is access to something if you choose to have it” (Consultant B, p. 3).
Connecting to youth in remote areas was a unique barrier, such as youth privacy in accessing mental health services,
… kids who don’t have access to a device, or who don’t have connectivity, have less choices in the way that they reach out, and some don’t have any choice in the way they reach out, where they can’t. … Access to privacy, having the space to actually reach out to have a confidential conversation free of stigma. (Consultant C, p. 4)
Consultant C described that, “when live chat wasn’t available, the kids … could only reach out through a landline phone … – depending on your house, if you have crowded housing, it is difficult to find a private space to have a conversation” (p. 4) Additional resources, such as text support, offered covert and ongoing supports for youth,
… kids can do it so inconspicuously. They can be sitting on the couch next to their parents, and be texting … without the parents knowing, and they can retain the conversation for later. So, if they’re reaching out about anxiety, the crisis respondent might go work with them to go over let’s say some breathing exercises, something to help calm them down. Next time, when they’re not engaged in the conversation, they might be feeling the same way, and they refer back to the conversation that they saved and go through the breathing exercises. (Consultant C, p. 4)
Consultants described the necessity of ongoing, flexible funding to be responsive to their communities, especially in the context of systemic, historical underfunding for Indigenous services.
Participants described substantial gaps in funding and infrastructure of Indigenous organizations, which posed additional barriers to pivoting to online service delivery, “I think that it’s fair to say that Indigenous organizations have been chronically underfunded in many ways for decades. … I’m not sure if you’ve ever been properly funded, in fact. … you don’t tend to see Indigenous organizations with state-of-the-art IT systems and updated infrastructure” (Consultant A, p. 4). Investment was not only required due to longstanding systemic factors, but also the need to continue supporting the impact of COVID-19 on clients into the future,
We’ve seen an outpouring of money. So, the first year of COVID was great. … tons of money allocated to support mental health and to support organizations to pivot … My only concern is, how long will that continue? Because, you know, this is not going away in the fall, in the summer. … Even if we get every Canadian vaccinated by the end of the calendar year, the mental health crisis is going to last for years, the damage has been done. And so we need steady funding to ensure that these services continue. (Consultant A, p. 5)
Community members had unique accessibility limitations and access, and therefore, services needed to be individually responsive, “And that’s why I say like the free, unrestricted dollars that allows agencies to say, OK, none of my family, none of our women, none of our men have devices. How are we going to stay connected? And you would have unrestricted funds to go and purchase these things” (Consultant B, p. 4).
In consideration of future steps, participants endorsed flexibility to support future generations,
Canada spends about a third less than other countries with our GDP on children and families. We are not investing in our kids and our kids are struggling. I think it’s really important for us to recognize as a country that we need to put kids before corporations. We need to invest in those sacred little bundles that come to us from the creator. (Consultant A, p. 5)
Participants described the necessity of appreciating mental health within a holistic, Indigenous-based framework,
I think also from an Indigenous perspective, it’s because we think about mental health a little differently. … our online cultural services also as supporting mental health. So, whereas we have like direct mental health counseling and clinical supports, we also have a lot of online groups that provide parenting support or substance abuse support or, you know, violence against women support or, you know, or just like culture night ceremony language. I feel like all of those also all of those online cultural events that we do are also supporting people’s mental health. (Consultant A, p. 1)
Consultant B described holistic approaches as foundational to services,
… we try to address mental health as a whole, in the person with emotional health, spiritual health, development and growth. A good model, addressing the person as a whole… we have a community wellness worker who will see the whole picture. It’s kind of our guiding principle, and that’s truly how we’re trying to operate. (p. 6)
This theme addresses the holistic efforts of supporting clients, such as curbside delivery of groceries, crafts, and programs,
We’ve created like a special gift bag that goes with the hamper. That’s like a healthy alternative. So a special bag with a special recipe each week where you can follow the recipe and all your ingredients are in the bag. And we encourage families to do it together or send us pictures of their end product, trying to still build that connection in different ways. (Consultant B, p. 5)
Additional supports for the health and wellness of community members came alongside various supports for children and family units,
And then one night is for women and the other night it’s for children because we wanted to be the children are suffering and they don’t always understand complex situations. …. So we created a sharing circle addressing mental health. It’s a little bit guided. It’s a little bit free with the traditional healers. And through that program, they’re also going to be receiving certain gifts and items. So journals for journaling, craft materials, beating stuff. (Consultant B, p. 1)
Consultant B described providing additional supports across areas including legal supports, housing, groceries, childcare, community gathering, cultural practices, and Elder teachings and ceremonies. Programming accessed by women who were navigating housing violence and faced isolation was vital; connection to online programming offered supports for housing, counselling, safety, and community mental health. While mental health was seen as inclusive of holistic health in many Indigenous service approaches, consultants described the significant mental health impacts due to COVID-19 risks, closures, and protocols; a high demand for emergent, flexible, and responsive support arose from the community. However, with high demand came longer waitlists, “For the first time in our 33-year history … we had waiting lists for our mental health services, and we haven’t been able to meet the demand because the pandemic has pushed people in such challenging ways” (Consultant A, p. 1). To address these immediate needs, service providers sought to expand with additional, flexible resources to support their community, “We also last month launched an afterhours mental health support line that’s new for [the organization]. … people can call and then have like a crisis clinician help them and de-escalate the situation they may be dealing with and then also refer them to other services” (Consultant A, p. 2).
To address the rise of mental health challenges in the community, Consultant B described creating additional mental health services, such as a weekly group, and an Indigenous clinical therapist. Consultant B described the importance of such supports,
… But I think when you’re thinking about mental health in the community, it’s not this it’s not that black and white mental health diagnosis … I think that our healers have really seen a value to reach out to folks who have mental health diagnoses, but also who just need stability in their overall wellbeing. It’s all sort of circular and tied into each other. What we’re trying to do with the traditional healers is, is instead of doing ceremony with community - which we do offer – it’s, ‘how can we also empower that person to understand a community for themselves?’ (p. 6)
Consultant C described teaching mental health skills, the importance of good relationships, and self-care through professional and peer-based counselling supports through virtual methods was important to be flexible in order to meet youths’ needs,
Some kids prefer to use the text-based support even though we’re in-person counselling, because they just – it gives them time to kind of put things down, they can do it in the moment. … Other kids are – they don’t want to speak with someone that they might know, so they reach out to [organization] because they’re confident that what they say to us will remain confidential, and that they’re anonymous. (Consultant C, p. 6)
For Indigenous youth accessing mental health services, confidentiality for Indigenous youth is beneficial to avoid discrimination, “Discrimination in the healthcare system is another barrier that, you know, if kids reach out to us anonymously, they know that they’re not going to face discrimination because we can’t see them” (Consultant C, p. 6). Cultural integration for mental health supports also varies,
Some kids will want mental health supports that are based in culture … Some kids might be Indigenous, but they don’t identify in that regard, or they feel more comfortable with mainstream supports. So, I say this to put the emphasis on choice, choice in how they reach out, who they reach out to, and the nature of the supports that they receive. (Consultant C, p. 6)
COVID-19 was appreciated as having long-term mental health impacts that would require ongoing supports. Consultant A described, “…we need to understand that mental health is not an isolated issue. … It’s not a siloed endeavor. We need cross sectoral, interdisciplinary, cultural focused investments, and we need them now” (Consultant A, p. 5). Consultant B described the benefit of mental health and ongoing supports both throughout and following COVID-19,
We are seeing that mental health will become an issue as the pandemic carries on and post recovery. And that’s why we try to create the sharing circles and provide people with tools so that we’re a bit of ahead of the game in the sense that it doesn’t have such a bad impact as we progress through the through the pandemic. (p. 6)
Large-scale holistic supports were also recommended to addressing youth mental health and well-being,
I think we need a national strategy for children’s mental health and wellness. … I think that needs to be attached to a national funding formula that flows through transfer agreements to particular provinces. And there needs to be an Indigenous scope within the context of that. I think that we need some type of a federal office focused on the wellness of children that is connected to provincial counterparts. (Consultant A, p. 6)
Participants described the importance of cultural connection and land-based healing for balancing health,
It’s sort of bringing that reconnection back to culture because we think that that’s going to be where people find their grounding. When things get overwhelming, we’re going to be giving out drums or drum kits, rattles for children, all of these sort of traditional tools that we know is useful in difficult times and in positive times. (Consultant B, p. 1)
Land connection was seen as especially important while coping with the impacts of COVID-19,
And I think that’s really important because as Indigenous People, we know that land is an important part of holistic wellness. ….getting out on the land, you know, in a city like Toronto is amazingly restorative. And so we’re also providing those opportunities as well. (Consultant A, pp. 1–2)
COVID-19 limited land-based gatherings and ceremonies, pushing service providers to increase virtual programming. Cultural programming promoted much more than just traditional practices, “…while beading may seem like it’s just beading, it’s actually reconnecting women back to a traditional craft. And then how do we build off of that to further stabilize their situation?” (Consultant B, p. 5). Community connection helped people connect to additional supports,
If you’re an Indigenous woman facing violence or harassment, I think those safe outlets and assurance that something is there is going to make a big difference. Simple engagement through something online could mean that maybe they engage in all the different programs, and then they seek further support, and maybe they work with the case manager, and they see they see a counselor, and start that healing journey. (Consultant B, p. 3)
Consultant B described the initial stages of virtual community programming to support wellness (i.e., affirmations, journaling, and traditional crafts), family supports (i.e., children, family care), and expanded spiritual supports (i.e., medicines, teachings). The virtual transition to ceremonies was met with mixed responses from community members,
…there was some feedback that was not in favor of us sort of moving to virtual platforms for different ceremonies and services. But. With saying that we sort of put out a response that right now is the time where community and Indigenous women are going to be isolated more than ever, and to withdraw those types of services would do more harm than not. (p. 2)
Consultant B reported on the importance of community gathering, and the role of the organization to provide materials, such as medicines, and skills in ceremony to cope with life stressors,
… having those tools, those drums, the rattles, knowing how to do a full moon ceremony on your own in your home, those are going to be the tools that are going to keep us grounded and hopefully … lessen stress, lessen anxiety … we’re trying to provide the reminder of where we come from and your ability to connect on your own, so that when you’re faced with difficult days, you have your tool kit to ground yourself and have your connection and your identity that keeps us strong and that heals us along the way. (Consultant B, p. 3)
All consultants described the risk of homelessness or experiencing domestic violence required more community connection and support than ever when exploring pathways to stability and security.
Virtual ceremonies were provided on a frequent basis, as well as in individual meetings with clients to support well-being. Consultant A described new cultural supports through programming, such as Elder daily openings through social media,
… morning prayer and talk about the day. And more and more, community members are logging on to that. And it’s a way that they can connect to an Elder and feel supported, connected to community from wherever they are. … the audience for that has expanded to beyond Toronto. So, we are reaching people that we never reached before through our face-to-face stuff, because now somebody in Moose Factory or Moosanee or wherever else can log on. And so, we are able to see that we’re reaching broader people. (Consultant A, p. 2)
Virtual platforms have also supported Elders who may have mobility issues,
…some [Elders] are just old school in their protocol and don’t really feel like that’s what they should be doing, but do it because they need to support community, but would prefer not to. We have others who have blossomed. We have some Elders who have mobility issues … it would be really hard for them to get out to community because moving around is hard for them or painful for them. I’ve heard commentary from Elders and keepers that are like, wow, it’s way easier. I can reach way more people. (Consultant A, p. 3)
Elders were able to conduct ceremony with an audience from across Turtle Island. To accommodate Elder connection for community members, new services were created,
Women can call and get direct access to Elders of the community or seek certain staff in the agency or seek out relocation support. That was a direct response to the first wave of the pandemic and any mental health, because they could call it to speak to an Elder in the moment … But it also gave the Elders an opportunity to give back and continue working and giving, continuing to offer up what they offer up. (Consultant B, p. 6)
Services needed to be responsive, available, and expanded to community needs. Participants described working closely with their communities to find how to best reach community members coping with losses and crises concurrent with COVID-19,
COVID has been a horrible time of community loss. So many community members are dying. It’s rough, whether it’s the opioid crisis, or family violence, or suicide, or whatever else. We’re still having sacred fires for people, right. We’re still able to, in a safe way, have a sacred fire with fire keepers and distance and take care of that ceremony in a good way. So I think it is important to say that we are still doing face to face stuff when it’s absolutely needed. But we’ve also been able to innovate, to do things are aligned like never before to support community that way. (Consultant A, p. 4).
Consultant B further elaborated on the need to support community members across all pathways, “in all pockets of the community, we just wanted folks to feel like they had access to items or supports. Their various needs … basic needs, mental health, spiritual needs, they were all being met, and we hope to continue and to ensure that community feels heard and served” (p. 7). However, understanding and listening to communities required existing relationships to better understand unique community needs, “it’s different for every community, so those contacts will help us understand, you know, what are the best messages, what are the best communication channels to reach those youth, and also reach out to us in times of crisis?” (Consultant C, p. 2); however, these relationships need long-term establishment and connection, “we want to ensure that we have relationships in place with communities before they’re in a state of crisis, so they can reach out to us if they want our support” (Consultant C, p. 2). Community support and responsivity (i.e., ensuring community connection; evaluation; addressing spiritual needs) included the importance of having broad, accessible services, so that children and youth have options in terms of engagement due to the danger and high risk of community disconnection.
The COVID-19 pandemic had a tremendous impact on culturally based services. This scoping review found that during the pandemic, mental health services for Indigenous Peoples transitioned to a virtual format to reach community members. However, Indigenous cultures, communities, and methods are relational and experiential; therefore, the virtual format was often limiting the profound strength found in culturally based methods. The core values of many Indigenous communities and traditional practices required community gathering, connection, and ceremonial attendance, all of which were significantly impacted. Isolation and community disconnection had detrimental effects on the mental health of Indigenous community members; it became crucial that service providers assisted in cultural engagement through virtual platforms. Feelings of isolation were combatted by virtual streams, which sought to bring healing and wellness to Indigenous People (Urbatsch & Robledo, 2020). However, this required adaptation that challenged some traditional protocols, a challenging decision that hoped to increase accessibility and reach to promote ceremonial and cultural connection across Canada, particularly in remote areas where local access to ceremony was lacking or unavailable.
Importantly, the COVID-19 pandemic also marks a spiritual or thematic parallel to the cultural restrictions and isolation imposed during colonization. These restrictions are akin to a spiritual wounding in the foundations that maintain community strength and wellness, one that necessitates further ceremonial involvement for healing, supporting, and addressing the impacts of COVID-19 on Indigenous communities.
The scoping review and key informant interviews discovered a host of barriers to mental health service provision and online translation; most notable were the lack of funding for culturally based mental health services and pervasive lack of funding in support of Indigenous communities. Several papers included in this review identified the lack of specialized mental health services (Ineese-Nash, 2020; Júnior et al., 2020; Tanana, 2020; Wendt et al., 2021) and discussed how this was partially due to the lack of mental healthcare in Canada (Júnior et al., 2020), further exacerbated over the COVID-19 pandemic.
The consultants, resources, and literature at the time of this scoping review described overcoming technology barriers (i.e., maintaining ongoing internet connection) and access to digital devices (e.g., smartphones, computers, and laptops) were necessary for accessing programming and digital mental healthcare. Technology barriers were systemic, engendered from Indigenous poverty in remote and reserve communities, insecure and overcrowded housing, and especially challenging for those community members experiencing homelessness. Service providers, then, become unfairly responsible for addressing systemic gaps in technology accessibility due to poverty and infrastructure in Indigenous communities and must apply funding to ensure that devices are provided for consistent, stable access to community members and continue care. However, staff loss over the course of the pandemic increased burdens and overworked remaining workers, greatly impacting the availability and quality of care their clients receive.
Limitations of this review include the number of articles included. Even with a wide search of multiple databases, articles may have been missed, especially relevant grey literature studies which were not included in academic literature databases. Despite this limitation, the findings from assessing the current literature and the key informant interviews provide important clinical significance regarding community-based mental health support and concrete ways for Indigenous mental health supports to improve their services during a pandemic by highlighting the current gaps in service provision and the resources needed to deliver services in an accessible way.
Increasing funding for Indigenous services is a core recommendation based on the results of the scoping review. Increased resources can improve ongoing services, technological infrastructure, and service capacity. Most Indigenous programs are funded by various levels of settler governments; holding government accountable and demanding policy change are needed.
Second, Indigenous communities need to have more sovereignty over their mental health services. This review found that Indigenous community-based knowledge and working with Elders and community leaders were embedded in programs and services that were successful in supporting peoples’ mental health. Indigenous-driven, created, and delivered services only seem to happen with Indigenous communities in charge of their own services.
A final recommendation is that cultural safety be centred in the development and delivery of Indigenous mental health services. It is clear from the results of the review that the ongoing process of systemic colonial harms on Indigenous Peoples continues to pervade mental health services. These harms of racism and discrimination exacerbate risks and health barriers and increase concern for more significant negative mental health outcomes during a pandemic. Additionally, services that focus on strengths (such as culture, spirit, ceremony, and creativity) of Indigenous Peoples can provide resistance to these harms.
This work was supported by the ON-NEIHR under Grant [number 508507].
The authors have no conflicts of interest to declare.
*The University of Toronto, Toronto, ON, Canada.
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Shkaakaamikwe gchi twaa miigwewin (Mother Earth’s Gift): A national network for ending Indigenous illness and promoting Indigenous mental health and healing | ||
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Correspondence to: Sabina Mirza, 155 College St, Toronto, ON, M5T 3M7, Canada. E-mail: sabina.mirza@utoronto.ca
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. For commercial re-use, please contact sales@sgpublishing.ca.
Journal of CSWB, VOLUME 9, NUMBER 2, June 2024
