i THE VOICES OF INDIGENOUS YOUTH AROUND MENTAL HEALTH SERVICES by Tracey Tantrum BA in Child and Youth Care, University of the Fraser Valley, 2021 MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in the School of Social Work and Human Service UNIVERSITY OF THE FRASER VALLEY Fall, 2022 All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other means, without permission of the author. ii Approval Name: Tracey Tantrum Degree: Master of Social Work Title: The Voices of Indigenous Youth around Mental Health Service Examining Committee: Leah Douglas Graduate Program Committee Chair Associate Professor & MSW Program Chair School of Social Work & Human Services Timothy Dueck Senior Supervisor Assistant Professor School of Social Work & Human Services University of the Fraser Valley Brianna Strumm Second Reader Assistant Professor School of Social Work & Human Services University of the Fraser Valley Date Defended/Approved: iii Abstract The research indicates significant unmet needs surrounding mental health services for Indigenous peoples. Most mental health services have not adapted to Indigenous clients' needs, reflected in the low utilization rates (Crowe-Salazar, 2007). The need for effective treatments when working with Indigenous peoples is recognized within the research. According to Allen et al. (2020), Indigenous peoples face health care systems that fail to reflect or pay attention to the cultural worldviews and definitions of health that they maintain due to the influence of a biomedical approach to health care, including mental health. According to Stock et al. (2017), more emphasis has been placed on the importance of effective engagement with Indigenous communities and professionals. Engagement with Indigenous communities and the development of respectful and trusting relationships are necessary for success (2017). Nelson and Wilson (2017) emphasize that as a group, Indigenous peoples all over suffer from an unequal burden of mental illness. Research indicates that we should be careful about speculating about the pervasiveness of mental illness in Indigenous peoples without taking into consideration colonial processes and structures. Despite a significant amount of health research detailing disparities in morbidity and mortality rates for Indigenous peoples, there appears to be far less research regarding mental health and, in particular, the mental health of Indigenous youth (2017). Through a critical review of relevant empirical and theoretical literature, this paper examines barriers to mental health services for Indigenous peoples, focusing on the voices of Indigenous youth through an anti-oppressive lens. The literature review draws on a two-eyed seeing approach to examine biomedical approaches and Indigenous approaches. The strengths and limitations of the biomedical approaches are analyzed in this paper. Culturally safe practices will iv be explored to support decolonization and better inform mental health interventions for Indigenous youth. v Acknowledgement I would like to express my sincere gratitude to my research supervisor, Assistant Professor of Social Work Timothy Dueck, and my second reader Assistant Professor Brianna Strumm, of the University of the Fraser Valley. Professor Dueck’s guidance throughout this research has been invaluable. His vision, sincerity, and unwavering APA 7 guidance have genuinely informed my practice and writing. He has taught me to narrow down the research and to present the research as concisely as possible. It was a great privilege to study under his guidance. I am incredibly grateful for his support. I am grateful to my family for their love, support, and understanding. I am very much thankful to my children for their understanding of my lack of time and devotion to completion. vi Positionality Acknowledging positionality is vital because it forces us to recognize “our own power, privilege, and biases as we critically analyze power structures” (Richie et al., 2015, p.8). Positionality is necessary for Indigenous methodologies (Redvers, 2020). Recognizing positionality is essential to better understand our paradigms through self-reflection. It also comes from the knowledge that the “research is often outside of ourselves and interconnected with ourselves since the researcher and researched interact together” (Richie et al., 2015, p.8). I identify as a divorced, Caucasian, fourth-generation Canadian woman. I am a mother, an aunt, a grandmother, a sister, a daughter, and a friend. I am the middle child born to Canadian parents. I was born and raised in British Columbia on the traditional territory of the Stó:lō people. I am able-bodied and educated. My social position and power as an educated white woman have afforded me unearned privilege that many of those I speak about do not have. I recognize I have outsider status, and my worldview impacts my position as a researcher ontologically and epistemologically. I am actively working towards the process of decolonization and an anti-oppressive framework. My research interests reflect my career experiences working with Indigenous peoples. Over the years, I have endeavored to advance my understanding and knowledge of Indigenous worldviews. As a Caucasian woman working primarily with Indigenous children, youth, and families, I strive to approach my work and research from a two-eyed seeing framework. vii Table of Contents Approval ......................................................................................................................................... ii Abstract .......................................................................................................................................... iii Acknowledgement ......................................................................................................................... v Positionality ................................................................................................................................... vi Introduction ..................................................................................................................................... 1 Theoretical framework .................................................................................................................... 4 Methods........................................................................................................................................... 6 Thematic findings from the literature ............................................................................................. 7 Causes of Indigenous Youths' challenges within the mental health system ................................... 7 Colonization and its impacts on mental health ........................................................................... 7 Suicide......................................................................................................................................... 8 Indian act ..................................................................................................................................... 8 Residential School ...................................................................................................................... 9 Intergenerational Trauma/ Historical Trauma .......................................................................... 11 Biomedical (Western) Ideology ................................................................................................ 12 Protective Factors.......................................................................................................................... 13 Resiliency .................................................................................................................................. 13 Indigenous Ideology.................................................................................................................. 14 Importance of community ......................................................................................................... 15 Connection to culture/cultural identity ..................................................................................... 16 Connection to the land .............................................................................................................. 17 viii Two-eyed Seeing ...................................................................................................................... 18 Moving forward ............................................................................................................................ 19 Voices of Indigenous Youth ..................................................................................................... 19 Removing Barriers to Service ................................................................................................... 20 Promoting Cultural Humility .................................................................................................... 23 Facilitating Holistic health ........................................................................................................ 25 Comparing deficit-based and strength-based services .............................................................. 27 For further consideration............................................................................................................... 28 References ..................................................................................................................................... 32 1 Introduction Regardless of the significantly higher rates of mental health issues in Indigenous communities compared to the rest of Canada, Indigenous people's mental health services are underused. “Indigenous youth in Canada, Australia, New Zealand, and the United States suffer from higher rates of stress, depression, and anxiety and higher rates of self-harm, suicidal ideation, and suicide than non-Indigenous youth in all four countries” (Jongen et al., 2020, para. 8). The research proposes that this is partly due to most services being based on nonIndigenous perceptions of health and healing (Stewart, 2008). According to Allen et al. (2020, p.1), “Indigenous people in Canada face significant barriers in accessing and using health care services, be it through racism, aggression, disrespect, differential health care, loss of language, and lack of trauma-informed care." Allen et al. (2020) state that mental health services are frequently culturally inappropriate and incongruent, resulting in many individuals not receiving lasting mental health services. The paradigm of Western research highlights positivism and objectivity, which can downplay ethics, location, and experience and thus further marginalize certain groups (Reid et al., 2016). Katapally (2020) states that the mental health of Indigenous youth (13-18 years old) is a crucial public health issue that cannot be addressed with a standardized approach. Indigenous mental health requires practices grounded in an Indigenous paradigm (2020). Based on Stewart’s (2008) findings, Indigenous mental health and wellness concepts differ from those of North American society. Brady (2015) states that the problem is developing knowledge and skills for working with Indigenous peoples, including cultural self-awareness, understanding the clients' worldview, and culturally sensitive working relationships. Building relationships with communities should 2 involve acknowledging traditional methods of healing as necessary. Counselors and social workers should integrate Indigenous methodologies when clients prefer them to prevent continued marginalization. Dudgeon and Bray (2017) discuss blending traditional and Western therapies such as two-eyed seeing as beneficial when working with Indigenous peoples. Roy et al. (2015) state that Western approaches generally follow medical models of individual-level pathology. Traditional Indigenous treatments are usually more holistic and keep the individual interconnected with the community (2015). “Treatments may include sweat ceremonies; practice is performed in a heated circular hut that uses heat and steam to purify the mind, body, and spirit; smudging, burning of traditional medicines (herbs) in a bowl or shell to cleanse people and places; the use of drums and songs to connect to the creator and circles, where everyone is equal, and information, spirituality, and emotions are shared” (Marsh et al., 2015, para. 7) There have been studies dedicated to understanding the disproportionately high rates of mental health issues among Indigenous youth. World Health Organization (2007) recognizes colonization as an underlying cause of Indigenous mental health. Colonization has drastically impacted Indigenous peoples, especially regarding the mental health of Indigenous adults and youth. An example from Brady (2015) states that high rates of suicide and mental health issues in the Indigenous population, particularly youth, could be partially linked to the effects of colonization. Historical trauma caused by colonialism is more complicated than biomedical psychiatric definitions of Post-Traumatic Stress Disorder (PTSD) concerning time, social collectivity, and experiences (Dungeon & Bray, 2017). Colonization and forced assimilation have negatively affected Indigenous peoples’ culture, language, existence, and ways of life. (Allen et al., 2020). Impacts of colonization, such as the legislation of the Indian Act, residential schools, historical and intergenerational trauma, and child apprehension from the child welfare system, 3 have caused significant trauma to Indigenous peoples and communities (Gone et al., 2019). The impact of trauma, mainly historical trauma or intergenerational trauma, is an essential factor in understanding the circumstances of Indigenous young peoples (Ralph & Ryan, 2017). Indigenous peoples' experience of trauma has been related to recurrent exposure to severe, multiple, and repeated stressors over time. The cause of this is family and communities' struggle with the ongoing impacts of colonization, dispossession, and oppression and the effect throughout generations (2017). Broken promises and discrimination have harmed the relationship between Indigenous groups and the government of Canada. Crowe-Salazar (2020) states that Canada has never officially admitted that genocide occurred against Indigenous peoples in Canada. The literature reflects that genocide is generally not used; instead, loss of culture is discussed (2020). Indigenous policies have resulted in inequalities within many systems, impacting the ability to act from an anti-oppressive lens in many instances. Using decoloniality in health research means creating a critical understanding of the beliefs, motivations, and values that inform policy and practice in order to make room for Indigenous ways of knowing, interpreting, and caring (Trout et al., 2018). Policies need to acknowledge the essential role of Indigenous communities in supporting Indigenous rights, interests, and responsibilities that serve the health and wellness of the individuals within the community (Reid et al., 2017). This paper will examine the causes of Indigenous youths' struggles with mental health and issues with the mental health system, focusing on colonization and its effects on Indigenous youth and protective factors and resiliency. This paper is a thematic literature review, using academic literature to analyze biomedical critically (Western) and Indigenous perspectives and barriers to the mental health system for Indigenous youth. Empirical and theoretical journal articles from web searches and online through the UFV library and Health and Human Services 4 library database searches were used to complete this literature review. A two-eyed seeing approach, postcolonial theory, and Indigenous perspectives were used as the theoretical framework. The following questions guide this literature review: 1. What are the barriers to Indigenous youth seeking mental health services? What impact has colonization had on the mental health of Indigenous youth? 2. What is the impact of the biomedical and Indigenous models of mental health on Indigenous youth? What are the strength and limitations of these models? 3. How do Indigenous people’s strength and resilience promote mental health and wellness despite higher risk of outcomes? 4. What changes are necessary for social workers working with Indigenous youth? This paper will introduce the research topic, rationale, research questions, theoretical framework, and methods to develop the literature review. This is followed by a more detailed description of the theoretical framework and methods used in this review. Following this, the literature is reviewed and discussed, including an analysis of the causes of Indigenous youth's struggles with mental health from a biomedical and Indigenous perspective. A focus on colonialism is included in this literature review and protective factors regarding Indigenous youth. Cultural safety is discussed as it pertains to moving forward with cultural humility to meet the needs of Indigenous youth best. The literature review will conclude with a summary and final recommendations for social work practice. Theoretical Framework An anti-oppressive practice framework guides my understanding of the research. There is concern that research within communities or with Indigenous peoples is dominated by Western biomedical discourse. Baines (2017, p. 4) describes anti-oppressive practice (AOP) as a type of “social justice-oriented social work theory and practice ."It is an approach to the intricacy of 5 today's social problems, recognizing multiple oppressions and the need for essential restructuring of all levels of society (2017). The main theories that guide this thematic review on Indigenous youth and mental health are Indigenous perspectives, two-eyed seeing, and postcolonial theory. I will use a critical paradigm to examine the societal structures and power relations and how they impact inequalities and disenable people while encouraging reflection and action on what is right and just. (Reid et al., 2017, p.12) “Postcolonial theories are concerned with historical, economic, cultural, and social health contexts” (Horrill et al., 2018, para. 10). Postcolonial theory provides a basis to view mental health issues and Indigenous youth. This theory helps to understand the importance of incorporating Indigenous worldviews into practice while recognizing that biomedical (Western) epistemologies are not always effective with Indigenous peoples. It is argued that postcolonial perspectives can provide insight into research with Indigenous communities in 4 interconnected ways: (a) issues of collaboration and “voice” in research development, (b) a commitment to engaging in critical analysis, (c) understanding how historical connections shape current health care and health outcomes, and (d) research’ colonizing potential (Browne et al., 2006). Indigenous perspectives represent Indigenous worldviews that differ from mental health's biomedical worldview. Indigenous perspectives emerge from holistic, community-oriented social structures that question binaries of gender, private ownership, or non-Indigenous government but offer a frame for family and kinship structures and seek to recover from colonization discrimination and trauma collectively (Reid et al., 2017). Two-eyed seeing acknowledges both methodologies (Indigenous and biomedical) without bias toward one way of seeing over the other; neither is superior. Two-eyed seeing is “To see from one eye with the strengths of Indigenous ways of knowing, and to see from the other eye 6 with the strengths of Western ways of knowing, and to use both of these eyes together” (Peltier, 2018, p.2). Methodology To develop this thematic review, an extensive search was conducted on Indigenous youth and mental health within the last 18 years. The literature review is based on electronic searches of various websites and database searches through the University of the Fraser Valley library and the Health & Human Services Library. Websites such as Statistics Canada, Here to Help, First Nations Health Authority, and the Aboriginal Healing Foundation were used. Databases searched included EBSCOhost, PubMed, PsycInfo, Sage Journals, Taylor & Francis Online, Researchgate.net, Science Direct, fpcfr, NCBI, and Semantic Scholar. The search will be limited to articles written in English and published from 2009 to the present. The investigation included the following search terms: “Voices of Indigenous youth and Mental Health” OR “Mental health and Indigenous youth” OR “Indigenous Mental Health” OR “Aboriginal Mental Health” OR “Mental Heath and Indigenous peoples” Or “Perspectives on Mental Health from Indigenous Youth" OR "Indigenous teenagers and Mental Health." The majority of the information reviewed includes peer-reviewed journals and book chapters. Also included is grey literature pertinent to the topic as there is limited information from the voices of Indigenous youth. Literature from various demographics was used, as there is little research available. A significant amount of the research identified comes from Australia and North America. Once the literature was reviewed, it was categorized into themes, including causes of Indigenous youth's struggles with mental health, protective factors, and cultural safety. It is necessary to acknowledge that non–Indigenous researchers conduct most research with Indigenous peoples. 7 This has been criticized for perpetuating, assisting, and increasing the practices of colonization (Ward & de Leeuw, 2018). Thematic Findings from The Literature Causes of Indigenous Youths Challenges Within the Mental Health System The literature revealed numerous factors that contribute to the mental health of Indigenous youth. Most mental health resources list causes of mental illnesses amongst Indigenous youth; however, there is little reference to the environment's impact on stress (Ward & de Leeuw, 2018). Often, the focus is on the individual and treatment in the context of mental health challenges, ignoring a range of factors that may affect Indigenous youth. Consequently, there may be an assumption that mental health issues are caused by individual weaknesses that can be addressed by education, training, or access to the proper treatment. (2018). Colonization and Its Impacts on Mental Health From the sixteenth century onwards, colonization devastated the Indigenous populations of North America. Boska et al. (2015, para 3) state, “in the mid-1850s, 90% of the population had died primarily from infectious diseases, conflicts, and forced displacement”. In Canada, Indigenous people have been subjected to “systematic oppression by the government that was designed to civilize, assimilate and eliminate their cultures” (Boska et al., 2015. Para 5). Katapally (2020) states that although Indigenous peoples were traditionally healthy people, intergenerational inequities caused by colonization have resulted in poor overall health. Indigenous peoples have experienced unthinkable interruptions, including epidemics, forced displacement, colonization, and genocide over the past few centuries. Indigenous youth do not fully understand these historical events, but the health consequences are well documented (Wexler, 2009). The health and wellness of Indigenous communities continue to be affected by Intergenerational trauma (Bombay et al., 2013; Katapally, 2020). It is especially difficult for 8 Indigenous youth due to the history of dispossession, as shown by “significant health disparities, high suicide rates, and poverty” (Katapally, 2020, para. 3). Suicide Recognizing that significant issues are surrounding the mental health of Indigenous youth, it is not unexpected that suicide rates amongst Indigenous youth are higher than their nonIndigenous peers (Ralph & Ryan, 2017). “The World Health Organization lists suicide as the second leading cause of death among young people ages 15-29 globally” (Katapally, 2020, para. 2). Indigenous youth in Canada continue to experience some of the highest suicide rates in the country (2020). Weiman (2006) states a critical need to develop a more complex understanding of youth risk factors for self-harm. Only then can more beneficial and culturally sensitive suicide prevention programs and interventions be created and delivered. The suicide rate differs greatly among countries and within populations; however, data show that youth, especially Indigenous youth, have higher mental illness and suicide rates in colonized countries such as America, Australia, and Canada (Katapally, 2020). Indigenous youth suicide can be attributed to many different risk factors and social determinants like those of nonIndigenous youth, such as mental illness, poverty, homelessness, and life stressors. However, the reality is that Indigenous youth suicide is attributed to the effects of colonization or other forms of marginalization (Millerick et al., 2020). According to Millerick et al., Indigenous youth suicide needs to be addressed differently than non-Indigenous youth suicide, primarily due to the effects of colonization (2020). Indian Act The Indian Act was enacted in 1876. This legislation aimed to eradicate Indigenous cultures by indoctrinating European cultures and beliefs (Boska et al., 2015). Loppie et al. (2014, p.6) state, “the Indian Act claimed that it was designed to protect the rights of Indigenous 9 peoples by recognizing the legal and ethical responsibilities of the Crown; however, it built federal structures that exercise control over Indigenous identity, lands, resources, languages, and cultural practices” (Boska et al., 2015, p.3). As part of the act, the federal government created and funded structures for band administration, education, and health care and made "status" Indians wards of the state (2015). Despite some revisions over time to the Indian Act, policies have continued to perpetuate the marginalization of Indigenous peoples. Menzies et al. (2014) define the Indian Act as a political identity that affects determinants of health and is one of the critical causes of the issues experienced by Indigenous youth. Policies within the Indian Act have restricted Indigenous people's control over their own lives and communities (Loppie et al., 2014). According to Richmond and Cook (2016), the effects of the Indian Act have served to perpetuate health inequality, including mental health, racism, and gender discrimination. The Department of Indian Affairs (DIA) was also created to manage policies concerning Indigenous peoples' economic, social, and cultural lives (Loppie et al., 2014). The formation of the DIA and the Indian Act began in a time of racism and oppression against Indigenous peoples (2014). Residential School One of the most harmful policies in Canada was the involuntary apprehension of Indigenous children from their communities and sent to Indian Residential Schools. This was part of the government’s plan to eliminate their cultural identities (Bombay et al., 2019). “The history of residential schools has been recognized as having long-lasting and intergenerational effects on Indigenous populations' physical and mental wellness in Canada” (Wilk et al., 2017, para. 1). Residential schools were created with the purpose of eliminating Indigenous language, traditions, and spiritual beliefs from Indigenous children so that they could become assimilable 10 into Western society (Wilk et al., 2017). According to Duncan Campbell Scott, head of the Department of Indian Affairs (1913-1932): I want to get rid of the Indian problem. I do not think, as a matter of fact, that the country ought to continuously protect a class of people who are able to stand alone… Our objective is to continue until there is not a single Indian in Canada that has not been absorbed into the body politic and there is no Indian question and no Indian Department, that is the whole object of this Bill (Boska et al. 2015, para. 4). Over 150,000 First Nations, Métis, and Inuit children aged 7-15 were forced to go to Christian-run schools between the 1870s and the mid-1990s (Boska et al., 2015; Wilk et al., 2017). The intent of the residential school system was “to civilize and Christianize Indigenous children” (Wilks et al., 2017, p, 2). In addition to severe underfunding, the schools were overcrowded, poorly maintained, lacked adequate sanitation and heating, and unable to provide adequate nutrition and health care (Boska et al., 2015) Many children endured physical, sexual, psychological, and spiritual abuse while attending residential schools as well the cultural and social effects of being forcibly displaced. All of which have had lasting impacts, including “health problems, substance abuse, suicide rates, criminal activity, and the disintegration of families and communities” (Wilk et al., 2017, para. 6). This large-scale removal of children disrupted families and communities; hence cultural traditions and beliefs could not be passed down, leading to loss of parenting skills and difficulty creating attachments (Boska et al., 2015). The residential school system was officially recognized as an effort at “cultural genocide” by Canada's Truth and Reconciliation Commission in their final report released in 2015 (Boska et al., 2015, para. 5). According to Wilk et al. (2017), the effects of residential school are intergenerational, with children of families that attended residential school exhibiting poorer 11 health status than those from families that did not. Multiple generations of families who attended residential schools suffer considerably more distress than those where only one generation attended. The consequences of residential schools are extensive and may include medical and psychological conditions, mental health issues, post-traumatic stress disorder, cultural effects such as changes to spiritual practices, diminished use of language and traditional knowledge, social consequences such as violence, suicide, and effects on gender norms, parenting practices, and family and community relationships (2017). Intergenerational Trauma/ Historical Trauma Intergenerational trauma continues to affect the health and wellness of Indigenous communities (Katapally, 2020). Indigenous peoples' experience of trauma has been connected to ongoing exposure to multiple, recurrent, severe, and prolonged stressors over time (Ralph & Ryan, 2017). The legacy of colonization, dispossession, and oppression has impacted families and communities throughout generations (2017). Kirmayer et al. (2014) state that intergenerational trauma is considered more complex than biomedical definitions of PostTraumatic Stress Disorder (PTSD) in terms of length, and social collectivity. It has been described as the “snowballing of experiences and the effects of colonization through systems of destructive policies dominated by settler societies” (2014, p. 3). Dispossession has resulted in a loss of identity, leading to significant health inequalities, high suicide rates, and poverty among Indigenous youth (Katapally, 2020). Intergenerational trauma exacerbates experiences of mental illness, often described as soul wounds, requiring care beyond a biomedical or physical approach (Allen et al., 2020; Gould et al., 2021). Many Indigenous peoples have been traumatized by historical events and other systemic factors, such as social inequality and racism, which have rendered them doubtful and less likely to use mental health services provided by practitioners who identify with the Western culture (2021). 12 Biomedical (Western) Ideology Most people in Indigenous communities see mental health and addiction in terms of wellness (Menzies et al., 2014). Crowe-Salazar (2020) states that traditional healing methods are rooted in the interconnectedness of social, physical, and spiritual environments. Indigenous peoples see mental wellness on a continuum where a person's place on the continuum results from internal and external factors (Menzies et al., 2014). According to Menzies et al. (2014, p.206), “mental health and mental illness reflect a Western paradigm characterized by dualism, negative labeling, and a focus on deficits: these terms do not exist in traditional languages”. Counseling services in Canada and the United States maintain a biomedical paradigm of health that differs from Indigenous peoples (Gone, 2004). These differences can produce a barrier to appropriate health services for Indigenous peoples who look for mental health support from professionally qualified counselors, including those who may be skilled in cross-cultural or multicultural approaches (Stewart 2008). Biomedical perspectives are a form of continued marginalization and colonization, as it does not recognize the Indigenous worldview of mental health and wellness (2008). According to Baine (2017), biomedical psychiatric systems can be experienced as racist. George et al. (2019) state that studies have shown that, in the establishment of conventional services, the government defines effective health care without taking into consideration Indigenous knowledge, beliefs, traditions, or customs. Therefore, “undermining self-determination, self-government, and the sovereignty of Indigenous peoples” (2019, p. 16). The health of Indigenous peoples is not best achieved by integrating them into mainstream services. The normalization process undermines diversity and cultural practices and does not consider how accessible services are to different cultural groups (2019). 13 Western approaches generally favor biomedical approaches that look at individual pathology that act to reduce distress, while traditional Indigenous therapies usually are “more holistic and keep the individual integrated within a collective” (Roy et al., 2015, p. 4). Western individualism creates barriers to holistic health for many Indigenous peoples (Carriere & Richardson, 2013, p. 9). A holistic understanding of wellness defines a notion of self that is “ontologically and epistemologically different from typical, biomedical Western notions of self” (Dudgeon & Bray, 2017, p. 1). Western or biomedical approaches depend on evidence-based practice, interpreted as empirically supported treatments; however, empirical evidence is often unrealistic in remote Indigenous communities and culturally inappropriate (Redvers, 2020). The biomedical model focuses on crisis and level of severity. It prioritizes short-term treatment, numbers of admissions and discharges, and medication-based interventions (Baine, 2017, p. 241). It highlights positivism and objectivity, which can downplay ethics, location, and experience and thus often further marginalize certain groups (Reid et al., 2016, p. 34). Protective Factors Resiliency Resilience involves how individuals overcome life’s challenges to achieve a sense of wellness. The connection between culture and these processes is clear; however, studies have neglected to explain cultural identity's part in Indigenous youth’s wellness and resilience (Wexler, 2009). Most mental health research on Indigenous youth has centered on the pervasiveness of mental health challenges and outcomes rather than resilience or protective factors. It is necessary to provide youth opportunities and settings where they can effectively and positively navigate challenges and improve and develop their strength and adaptive abilities. A focus on resilience means capturing the physical, mental, emotional, and spiritual qualities of 14 individuals and their communities, which is more reflective of Indigenous approaches to health and wellness (Macdonald et al., 2013) Research guided with an Indigenous paradigm seemed to focus on resilience and a decoloniality to build on their existing strengths. Resilience is recognized as vital for preserving and supporting youth mental health and safeguarding against possible threats to health and wellness throughout their lives (Jongen et al., 2020). Resilience interventions must combine culturally appropriate practices that are mindful of the contexts of youths' lives to be effective. Redvers (2020) states that culture and connection foster resiliency and address colonization's continuing legacy challenges. Indigenous Ideology Indigenous research has shown a need to develop approaches that are “methodologically and epistemologically aligned with Indigenous worldviews and are designed to embrace Indigenous ways of knowing” (Blodgett et al., 2013, p. 4). In promoting wellness in Indigenous communities, it is necessary to connect with cultural identity and practices within an Indigenous pedagogy (Redvers, 2020). Allen et al. (2020) state that adopting western tools and perspectives to assess or substantiate traditional Indigenous knowledge is problematic. It is a colonial approach that jeopardizes centuries of treaty relationships between sovereign nations by establishing one paradigm, worldview, or knowledge system over another. Traditional Indigenous knowledge and cultural practices can be difficult to appreciate if they are viewed from only an evidence-based Western biomedical perspective (2020). Hart (2010) discusses how Indigenous peoples are expected to conform to the Amer-European expectations of the world while disregarding their Indigenous perspectives. He states that Indigenous peoples are forced to validate the colonialists’ beliefs and sacrifice Indigenous worldviews and values (2010). 15 Wood et al. (2018) states that researchers need to reconsider how they conduct research to include perspectives that listen to the narrative and experience of those that navigate colonialism while creating spaces of healing. This places Indigenous perspectives, particularly of Indigenous youth, not only at the center of health narratives but in the examination of their health and interactions with their environments. Youth are crucial to the “production, reproduction, and transformation of societies and culture” (2018, p. 8). The perspectives of Indigenous people on health and wellness are informed by their cultural values, beliefs, and traditions handed down over generations. It is believed that holistic health is central to understanding wellness and emphasizes the interconnectedness of all life, the environment, and the universe (Priest et al., 2016). These Indigenous knowledge perspectives reveal the worldview contained in the Medicine Wheel framework (Ritchie et al., 2015). According to Stewart (2008), Indigenous perceptions of mental health and healing must be integrated into counseling as well as other efforts to support Indigenous mental health. “This includes framing mental health holistically within physical, emotional, mental, and spiritual dimensions” (Redvers, 2020, p. 92). Importance of Community Evidence emphasized the importance of establishing and maintaining solid relationships with family and community members (Macdonald et at., 2013). Stewart (2008) suggests that community is part of the holistic balance of a person's life; healing cannot occur without taking the community into consideration. Indigenous peoples’ mental health treatment may be more effective when the emphasis is placed on family and community connections as sources of healing and recognizes the significance of a collective identity (Kirmayer et al., 2003). According to Menzies et al. (2014, p. 209), “mental wellness is relational: strength and security are based on family and community”. Mental wellness is established in a sociocultural context 16 and embodies traditions, laws, and customs that promote and sustain wellness (2014). Even when Indigenous youth live away from their communities, a need to contribute, connect, and maintain relationships continue to be essential to youth success (Macdonald et al., 2013). Brady (2015) discusses the importance of interconnectedness throughout the research related to Indigenous health. Counselors must acknowledge the significance of interconnectedness for Indigenous peoples and be open and understanding to the involvement of family and community members. Involving family and community in treatment recognizes the value of caregiver relationships and family systems, as well as identifying traditional knowledge and expertise. These therapy models include caregivers in the therapeutic process to realize that relationships with others are essential to supporting lasting change for youth and provide caregivers with helpful tools and strategies (2015). Many instances of misdiagnosis, underdiagnosis, and overdiagnosis occur with Indigenous youth due to being evaluated outside of their community or preferred culture (Westermann, 2010). Indigenous peoples assessed in environments other than their own would significantly be more distressed than usual. Therefore, practitioners must ensure that assessments are used to match how Indigenous peoples are perceived within their culture (2010). Connection to Culture/Cultural Identity The United Nations states: “Indigenous peoples are inheritors and practitioners of unique cultures and ways of relating to people and the environment and are arguably amongst the most disadvantaged and vulnerable groups of people in the world” (Katapally, 2020, p.1). A common theme in Canadian Indigenous health research is culture as a cure; when interventions are holistic and informed by cultural knowledge and Indigenous worldviews, the likelihood of success and wellness increases (Allen et al., 2020). Identifying with one’s culture and developing a strong cultural identity is significant for Indigenous young people (Wexler, 2009). “Strong 17 cultural identity and cultural connectedness have been linked to better health, higher self-esteem, positive mental health outcomes, and lower rates of binge drinking” (Katapally, 2020, p. 2). Cultural characteristics are both internal and external and come from personal choices and influences from others (Wexler, 2009). Indigenous people's cultural identity permits them to think about healing possibilities and to connect with family, community, and Indigenous cultures through personal growth and development (Stewart, 2008). The development of a strong cultural identity can help Indigenous youth better understand their people, their past, and their present (Wexler, 2009). Indigenous youth’s resilience interventions also aim to strengthen cultural identity and cultural connection. It is encouraging to see that Indigenous models are based on cultural conceptions of resilience, wellness, and positive development, given the positive effect, cultural connections have on Indigenous youth (Jongen et al., 2019). Connection To the Land “Traditional land-based activities support Indigenous youth feeling more centered and connected to something outside themselves” (Brady, 2015, p. 102). Redvers (2020) states that knowledge holders describe the land as a healer and its role in physical, mental, emotional, and spiritual health. They talk about its essential connection with ways of being and seeing the world through their land-based traditional languages. They emphasized the “experiential language” of the land and described “land-based” as a lived connection built over generations and shared through the oral tradition and understood only through direct practices or experiences. “Landbased practices such as harvesting, hunting, education, ceremony, recreation, and cultural-based interventions are centered on Indigenous worldviews and understanding that identity is interconnected to the land” (2020, p.90). Nurturing this connection increases positive mental health outcomes with Indigenous peoples through a culturally appropriate lens (2020). 18 Janelle et al. (2009) reported positive results in improving cultural pride, a positive cultural identity, and prosocial behaviors using traditional land-based activities, suggesting that traditional land-based activities have the potential for children, youth, and adults. Redvers (2020) discusses how Indigenous peoples in Canada are revitalizing land-based initiatives that are embedded in the land, traditional knowledge, spiritual values, and ceremonies. The aim is to strengthen community resiliency and address challenges arising from a continuing legacy of colonization and land dispossession (2020). Two-eyed Seeing Etuaptmumk, or two-eyed seeing, was developed by Mi’kmaw Elders Albert and Murdena Marshall from the teachings of Chief Charles Labrador of Acadia First Nation in Nova Scotia (Dudgeon & Bray, 2017). Etuaptmumk is where health practitioners and researchers function through Western (one eye) and Indigenous knowledge (another eye). In the future, research, collaboration, and practice aiming to address power inequities and include Indigenous knowledge could be helpful, including holistic frameworks, methods of operation, and efficacy requirements (Allen et al. 2020). Gould et al. (2021) state that the two-eyed seeing perspective recognizes Indigenous knowledge as separate from Western knowledge while valuing both equally. This permits a more trustworthy examination of Indigenous mental wellness without ignoring the knowledge systems obtained from other cultural groups. Berry and Crowe (2009) found that non-Indigenous practitioners who were willing to listen, learn, and apply Western and Indigenous frameworks were more likely to be effective with Indigenous clients. The success of health policies within Indigenous communities is contingent on a bottomup approach that is culturally aware and strengths-based (Katapally, 2020). It is necessary to support strategies that empower Indigenous youth and promote two-eyed seeing solutions to engage youth in the twenty-first century (2020). Practitioners are encouraged to combine 19 multiple cultural worldviews and healing methods, such as two-eyed seeing, to provide adequate services for Indigenous communities that place community connectedness, culture, and cultural identity at the center of wellness (Gould et al., 2021). Incorporating cultural practices into biomedical (Western) counseling will strengthen cultural identity (Stewart, 2008). Moving forward Voices of Indigenous Youth There was limited research on the Indigenous population relating to mental health, and very few included youths and even less from the perspective of Indigenous youth. “The current discourse on the importance of Indigenous perspectives is clear” (Ritchie et al., 2015, p. 14). Ward and de Leeuw (2018) discuss how youth want to be experts in their own lives and their voices and stories honored. Despite evidence that youths' voices are imperative, the voices, perspectives, and expertise of Indigenous youths are underrepresented in public health research, programs, and services, resulting in harmful research and substandard public health programming and services (Hardy et al., 2020). According to the Family Caring Society (2019), youth made it clear that biomedical perspectives frequently have unfair consequences that perpetuate further harm within Indigenous communities. Indigenous youth talk about how research tends to constantly focus on the deficits in communities rather than the resilience that Indigenous youth exhibit and experience. Indigenous youth want to be defined by their strength and success (2019). Priest et al. (2016) discuss how children and youth are among the least recognized groups in research, with health and wellness defined and measured in relation to adults' experiences. Due to their lack of social power and immaturity, youth and children are frequently the most adversely affected by disadvantages (2016). According to Wood et al. (2018), researchers need to engage more with the perspectives and lives of young people in Indigenous communities and 20 create spaces in which Indigenous perspectives and epistemologies can be explored. Arellano et al. (2018) state that in program development, it is imperative that providing youth and community a voice holds equal importance to integrating culture. Maintaining flexible models creates the opportunity for youth to have a say in making decisions (2018). “Youth are at the forefront of change and are crucial to the production, reproduction, and transformation of societies and culture” (Wood et al., 2018, p. 8). Searching out Indigenous youth’s perspectives of health and wellness within the context of oppression experienced by Indigenous peoples shifts the focus on youth's experiences and strengths and privileges their standpoints (Priest et al., 2016). Indigenous youth not only need to navigate organizations and opposing narratives about their lives, but they are also the leaders of future generations. Practitioners must take Indigenous youth's well-being and perspectives seriously to decolonize and establish self-determining, healthy, and thriving communities. The voices and experiences of Indigenous youth must not be overlooked; rather, their voices must be at the forefront (Wood et al., 2018). Removing Barriers to Service Colonialism has imposed realities that negate mental and holistic wellness, such as isolation, displacement from family and community, fractured sense of belonging and identity, and denial of language and culture (Roy et al., 2015). Significant systemic and structural obstacles impede many Indigenous people's access to mental health services (Ralph & Ryan, 2017). For many Indigenous peoples, access to health care can be difficult with distance, transportation, cost, a lack of education, and the cultural appropriateness of services, as well as experiences of racism, discrimination, and lack of cultural sensitivity (2017). To alleviate the discord from a history of colonization and support mental wellness, Boska et al. (2015) suggest: 21 • Taking opportunities to talk with Indigenous peoples to learn about their perspectives • Read and become educated on the history of Canada’s Indigenous peoples • Acknowledge the effects of colonization are deeply rooted • Become culturally aware with an understanding of colonization and the current challenges that impact the mental health of Indigenous peoples. • Recognize that there is not a single pan-Indigenous identity. Learn about issues surrounding Indigenous peoples while being aware of the diversity of communities • Provide mental health services that are culturally appropriate and work respectfully within an Indigenous framework • Engage in respectful relationships with traditional healers and knowledge keepers • Recognize that local Indigenous knowledge must lead the development of mental health programs for Indigenous peoples’ Cultural differences between patients and practitioners have contributed to the lack of engagement of Indigenous youth in mental health services (Westerman, 2010). There is a history of distrust associated with biomedical health systems that may hinder healthcare access. Ralph and Ryan (2017) describe one of the barriers for Indigenous families and youth accessing mental health services as fear of unnecessary interventions from government organizations. There is also a shame connected with the experience of mental health disorders that hinders many Indigenous young people and others from pursuing help. Indigenous peoples and families will seek out mental health support only when there is a crisis (2017). Povey et al. (2021) state that considerations of language, diversity, and worldview differences are sometimes disregarded, 22 resulting in less meaningful or appropriate programs for the young people they are expected to serve. Countering Tokenism It is challenging to engage Indigenous clients due to a lack of access to services and cultural respectfulness. According to Berry and Crowe (2009), this is evident in the commitment to connect with families and Indigenous workers beyond tokenism. Research has shown a failure of mental health services to incorporate an understanding of Indigenous approaches to mental health (2009). When working with Indigenous communities, research that includes the misuse of sacred information such as stories, songs, and traditional knowledge is shared, resulting in the devaluing of knowledge and adverse effects on the community. Researchers that are outside the community have a potential for misunderstanding. Spending time in Indigenous communities is vital before starting the research in order to build trusting relationships (Redvers, 2020). In Canada, Indigenous healers and Elders are often hesitant to collaborate due to “concerns about overharvesting plant medicines, disrespectful treatment, cultural appropriation, unbalanced funding policies, tokenism, and loss of autonomy” (Allen et al., 2020, p. E215). Evidence indicates the importance of integrating cultural practices into Western counseling to strengthen cultural identity and promote health and healing (Stewart, 2008). One of the challenges in implementing effective programs and services where cultural differences exist is avoiding tokenism. Durey et al. (2014) state that practitioners often meet organizational criteria for professional development by ticking a box for participating in a workshop or seminar on cultural education. However, in this requirement of culturally safe practice, programs are not evaluated for whether Indigenous knowledge has been interpreted correctly in order to sustain improvements to practice (2014). Berry and Crowe (2009) discuss how it is often more 23 challenging to engage Indigenous peoples due to unavailable services and a lack of cultural awareness and respectfulness within those services, evidenced by such things as practitioners’ readiness to involve families and Indigenous workers beyond tokenism. According to Durey et al. (2014), a commitment to move beyond tokenism and engage profoundly with ethical practice at many levels is necessary. Standardized biomedical perspectives of care must be analyzed for effectiveness when working with Indigenous. White privilege can produce inequities in Indigenous health, and recognizing this is necessary to change the discourse that places Indigenous peoples at the center of the problem. (2014) Promoting Cultural Humility Addressing and recognizing the marginalization and discrimination against Indigenous peoples is significant when engaging with communities. Many spoke of the importance of cultural safety, “described as the experience of feeling safe and being an active contributor when receiving care or services," should be included in the work with Indigenous communities (Gould et al., 2021, p. 215). However, they also spoke of a system lacking in cultural competency has been described. Brady (2015) states that the problem is developing knowledge and skills for working with Indigenous peoples, including cultural self-awareness, understanding the clients' worldview, and culturally sensitive working relationships. Building relationships with communities should involve acknowledging traditional methods of healing as valuable. Counselors should include Indigenous methodologies when clients prefer them to prevent continued marginalization. However, a definition of cultural competence is limited (Brady, 2015). There is an ongoing debate about concepts of cultural competence for non-Indigenous workers and how these differ from common professional competencies (Stock et al., 2017). Ralph and Ryan (2017) state that practitioners need to participate in cultural competency training 24 before delivering services to Indigenous clients to have a sufficient level of cultural competence. Cultural training ought to incorporate power relations and the understanding of the utilization of racialized language (2017). Durey et al. (2014) suggest that to develop critical consciousness, there is a need to think about our own biases, assumptions, and world views and how they have an effect on perceptions of diversity and power dynamics when relating to those from different cultural backgrounds. Cultural competency is presented as a framework for working with Indigenous peoples; however, according to Danso (2018), various definitions and conceptualizations have created controversy around the construct. This has resulted in calls to replace cultural competency with cultural humility. Lewis et al. (2018) state that the cultural humility model believes practitioners can never learn enough to be genuinely competent in a culture. However, it encourages practitioners to seek knowledge and resources regarding their clients’ cultural beliefs. A cultural humility approach entails continual critical self-reflection to establish partnerships with Indigenous peoples and their communities, where knowledge, values, and ways of being are honored (2018). Rincon’s (2009) model of cultural humility is a model that creates a framework for increasing knowledge, awareness, and skills that uses a decolonizing perspective. It is comprised of six key components: (a) critical self-reflection that includes understanding biases and assumptions; (b) understanding that one culture is not better than another; (c) admitting a lack of knowledge about the culture or context of our clients; (d) seeking out knowledge and resources about the contexts of our clients; (e) recognizing the client as the expert on their cultural, values, and beliefs; and (f) place assumptions aside. Incorporating these components creates a framework for increasing knowledge, awareness, and skills strengthened by a decolonizing 25 perspective (2009). Practitioners working with Indigenous peoples must come from a place of cultural humility, where the client’s culture is valued and honored (Berthold, 2016). Facilitating Holistic Health Indigenous wellness models are often more holistic and highlight the interconnectedness of mental, emotional, spiritual, and physical dimensions of health and how these dimensions are dependent on one's broader relations (Wood et al., 2018). A holistic understanding of life includes the well-being of the individual and the well-being of their family and community (Ralph & Ryan, 2017). Priest et al. (2016, p. 644) found that "Indigenous children and youth understand holistic ideas of health and wellness that incorporate physical, psychological, social, spiritual, and cultural domains as well as social and structural factors such as racism and loss”, These factors need to be supported for good health and wellness. These views align with Hardy et al. (2020), who calls for research on interventions that respect cultural perspectives and recognize that Indigenous youth holistically understand health as being interconnected to culture and community. Carriere and Richardson (2013) discuss various Indigenous models that have been used to represent holistic wellness. These include the Cedar tree, the Medicine Wheel, the Medicine Wheel of Responses, The Circle of Courage, The Sacred Tree, and the Tree of Life, which can be a bridge for considering the individual within the family, community, and society. From a Western perspective, Urie Bronfenbrenner's ecological systems model can also be a helpful bridge. This type of holistic or interconnected ecological framework is consistent with the Indigenous worldview of individuals' relations and connections in their environment (2013). It is important to note that different communities may use other models to represent holistic wellness. It is, therefore, essential to seek clarification and understanding of the cultures within the work environment. Berry and Crowe (2009) state that there have been multiple attempts to describe 26 Indigenous mental health concepts; however, there has been a persistent focus on the holistic nature of health and well-being. Connecting with self is a holistic process that includes merging the physical, mental, emotional, spiritual, and a possible fifth dimensions of the medicine wheel around balance and holistic wellness (Richie et al., 2015). The circular shape represents the interconnectedness of all aspects of ourselves, including the connections with the natural world (Joseph, 2020). The medicine wheel is interpreted differently in each culture, and the order and colors are not the same in each culture. Joseph, (2020). This contrasts with a biomedical model of health where mental health is dealt with in isolation from other concepts of health. A holistic approach to mental health and wellness should not be considered an alternative to conventional mental health services. It should become a genuine and accepted part of mental health services to the larger community (Stewart, 2008). It is necessary to normalize culturally appropriate practices and programs to facilitate Indigenous youth's mental health, given the role culture plays in holistic health (Katapally, 2020). In an Indigenous counseling relationship, practicing holistically means including all dimensions as the focus of mental health services (Stewart, 2008). A holistic understanding of wellness describes a concept of the self which is “ontologically and epistemologically different from individualistic biomedical conceptions of the self” (Dudgeon & Bray, 2017, p. 1). 27 Comparing Deficit Based and Strength-based Services Deficit-based approaches to analyzing Indigenous communities can, directly and indirectly, perpetuate opinions that Indigenous communities are high-risk and unfavorable environments (Wood et al., 2018). Ward and de Leeuw (2018) state that researchers have been criticized for perpetuating, aiding, and intensifying the process of colonization, mainly when it takes a deficit-based, pathologizing view of Indigenous peoples. Damage-centered narratives conceal Indigenous peoples’ strength, resilience, and survival (Wood et al., 2018). These deficit approaches also referred to as damage-centered research, portray Indigenous communities as broken. Deficit-based analysis neglects to include Indigenous-led narratives of their communities, often perpetuating opinions that Indigenous peoples live depressing and miserable lives. Wood et al. state that deficit narratives can increase trauma and perpetuate harmful stereotypes that threaten Indigenous communities daily. It is, therefore, necessary that researchers reconsider how to conduct research to incorporate approaches that incorporate the narratives and experiences of those who navigate colonization while creating spaces of hope and healing (2018). A strength-based approach must be used that recognizes and builds on the strengths of Indigenous peoples to support change within communities (Blodgett et al., 2013). Researchers have acknowledged that strengths-based perspectives that consider contextual influences may be helpful to promote the positive development of Indigenous youth (Arellano et al., 2018). It is necessary to consider community strengths if health research contributes to building healthier and thriving Indigenous communities. Researchers are encouraged to focus on the numerous examples of strength and resilience that have permitted communities to survive and succeed, despite the adverse characteristics of their environments (Wood et al., 2018). 28 A strengths-based approach moves the deficits away from the individual while placing the importance on problems in the appropriate context, such as the oppression of residential schools (Katapally, 2020). Strength-based frameworks enhance Indigenous youth's social and emotional well-being, promoting behaviors in navigating towards resources that can maintain their health and wellness under challenging times (Jongen et al., 2020). For Further Consideration It is imperative, moving forward, that we change the way we practice and do research considering Indigenous peoples, youth in particular. Indigenous peoples in Canada continue to confront significant barriers to accessing and utilizing health services. These barriers include colonization, racism, disrespect, lack of trust, stigma, biomedical perspectives, and lack of trauma-informed services. Allen et al. (2020) state that mental health services are not reflective of or grounded in Indigenous worldviews and are frequently incongruent and culturally unsafe. Counselors should integrate Indigenous methodologies when clients prefer them to prevent continued marginalization. Therefore, it is crucial to provide services from a two-eyed seeing perspective when working with Indigenous peoples. Dudgeon and Bray (2017) discuss the benefit of blending traditional and Western therapies, such as two-eyed seeing. Western approaches typically follow bio-medical models that look at individual-level pathology. However, Indigenous therapies are more “holistic and keep the individual integrated within a collective” (Roy et al., 2015, p. 4). There is concern that research within communities or with Indigenous peoples is dominated by Western discourse. Promoting wellness in Indigenous communities is necessary to reconnect with cultural identity and practices within an Indigenous pedagogy (Redvers, 2020). The paradigm of Western research highlights positivism and objectivity, which can downplay ethics, location, and experience and thus further marginalize certain groups (Reid et al., 2016, p. 34). 29 Lewis et al. (2018) state that social workers working with Indigenous peoples must continually practice from a position of cultural humility, where the client's culture is valued and honored. Social workers must gain ethnocultural empathy and understand the perspectives and beliefs of members of a different cultural group (2018). Many articles discussed cultural competency or cultural safety; however, few spoke of cultural humility. Cultural competency and safety give the perception that one can become culturally competent; however, can one ever learn enough to be skilled in a culture, especially a culture outside ourselves. A cultural humility perspective requires social workers to engage in critical self-reflection so that we can create and maintain partnerships with our clients and their communities where their knowledge, values, and ways of being are valued (Lewis et al., 2018). According to Danso (2016), acknowledging one's biases and cultural misunderstandings and participating in continuous self-reflection while challenging power dynamics is key to working from a place of cultural humility. The definition of cultural competency was recently revised, and cultural humility was introduced; this emphasizes the significance of cultural humility in culturally competent practice (2016). Peltier (2018) states that Indigenous peoples call for meaningful and respectful research derived from Indigenous worldviews. In the past, researchers had little knowledge of Indigenous worldviews or communities, and analysis was often done using a helicopter approach; they would fly in, gather the information and leave. This contributed to mistrust and misinformation (2018). Voices of Indigenous youth are lacking in research and mental health resources (Ward and de Leeuw, 2018). To “decolonize and create self-determining, healthy, and thriving Indigenous communities, social workers must take the perspectives of Indigenous youth seriously” (Wood et al., 2018, p. 144). The voices, experiences, and perspectives of youth must not be overlooked; their voices must be heard (2018). Silencing Indigenous understandings of 30 mental health resources perpetuates colonialism and reinforces dominant biomedical discourses (Ward and de Leeuw, 2018). First Nation Child and Family Caring Society of Canada (2019) states that research must include the space for communities to lead and define the research. Using distinction-based methods does not honor cultural worldviews or the diversity of youth experiences. Research needs to be conducted in culturally appropriate ways that are acceptable to the community. Elders and Knowledge holders must be honored and respected for the information they hold (2019). Liebenberg et al. (2017) state practitioners need to respect youth as people all on their own, with unique needs, experiences, and perceptions. Participatory action research that focuses on flexibility, adaptability, and the importance of community partners’ role in establishing honest and trusting relationships between youth and the researchers has a significant impact on the data, findings, and the dissemination process (2017). An ethical consideration regarding many articles is the lack of evidence around researchers’ biases, assumptions, and social location or positionality. Reid et al. (2017) discuss the importance of anti-oppressive research by questioning assumptions such as objectivity and hierarchies of evidence of positivism. The articles that were done with Indigenous communities did not state who has ownership over the research or where the research information would be located. This could be an ethical consideration as ownership entails protecting Indigenous information. The impact of the researcher's positionality based on an Indigenous approach appears to be significantly important. Indigenous researchers resist hierarchical, objectivist research that privileges quantitative methods that diminish the role of subjectivity in research (Reid et al., 2017). Few articles integrated an Indigenous or interactive paradigm where knowledge is obtained by participating subjectively in the world. Most studies appeared to be based on the positivist paradigm and were concerned about controlling environments. 31 Many articles discussed adding cultural elements to a program to help Indigenous peoples feel comfortable. A couple of articles spoke of using symbolism such as the medicine wheel or cedar tree; another discussed having sweetgrass in the meeting room. However, a few articles discuss how “adding cultural elements to a pre-existing program can be ineffective and even tokenistic without broader engagement and understanding of Indigenous worldviews” (Roy et al., 2015, p. 74). According to Bess et al. 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