Healing Through Etuaptmumk: Paths to Wellness for Indigenous Youth of Newfoundland and Labrador

Introduction

What does it mean to speak about Indigenous youth mental health? When trying to encompass such a broad scope, it is easy to make sweeping generalizations to provide a succinct response. However, one can make the error of forgetting the rich and diverse practices across nations whose people have distinct cultural and lived experiences. Indigenous youth in Newfoundland and Labrador cannot be grouped into one category, and it would be unjust to expect healing to come from colonial systems which have produced more harm than good. Innu, Inuit, and L’nuk (Mi’kmaq) youth share common experiences and traumas; however, each nation and community has ways and knowings which cannot be conflated. The forgotten and ignored youth of Newfoundland and Labrador are in crisis, despite the Truth and Reconciliation Calls to Action being put to the Canadian Government and people a decade ago. ¹

This article will examine youth mental wellness across nations in the easternmost province of Canada. What is working? Where are the gaps? And most importantly, how can we move forward in a good way to support youth to find appropriate ways to healing? It will examine and consider how clinical and community supports can work together to help youth find appropriate ways to healing. This discussion will be based on Etuaptmumk, “Two-Eyed Seeing,” developed by Elder Albert Marshall. ² With Etuaptmumk, considering both Indigenous and Western perspectives, a richer understanding can be offered on how to create systems change and open doors to healing. Overlaid on this perspective will be the overarching words of Hope, Purpose, Belonging, and Meaning. According to the Thunderbird Partnership Foundation, ¹⁵

“These words come from Elders and Knowledge Keepers who, despite being from different Nations with different cultural practices, agreed that wellness happens when we have Hope for the future, a sense of Belonging, that we understand our lives have Meaning and that we have found our Purpose whether it is through education, employment, caregiving activities or cultural ways of being and doing.”

Wellness cannot be achieved without all these benchmarks. Each person must find ways to have hope, purpose, belonging, and meaning within their own community so that they can thrive and be well. The question is how to incorporate traditional healing practices alongside a Western system which, typically speaking, views this from a deficit perspective? There is a way forward to true reconciliation, so that clinical and community-based models can support youth to increase resilience, develop protective skills, reduce barriers to access, and celebrate the differences which allow for a rich and deep understanding of the self within community. Each person is an expert in their own experience and must be at the centre of their own wellness plan.

The barrier landscape of accessing appropriate healthcare in the province of Newfoundland and Labrador is a common experience across nations, according to self-reports by Indigenous youth. Despite Call 22, which states “We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients,” ¹¹ Indigenous youth report having little to no access to appropriate mental health supports, rating their mental wellness as poor, and feeling retraumatized by a system which is intended to support them.

When asked to rate current mental health services in the province, with 1 being completely inaccessible and 5 being completely accessible, Indigenous youth interviewed were clear that the system is not designed to be accessible. ³

Youth Respondent 2, ⁴ while being interviewed, stated “you’re probably not going to get anything good here.” When prompted to explain further, they said in their experience navigating the system, clinicians “don’t ask about [culture] and don’t care about [culture].” In the years since calling for change across Canada, Indigenous youth in this province are still feeling lost in a system which invalidates their experience, creates measures from a deficit perspective, and does not provide agency for the youth to be at the centre of their own care.

There are no easy solutions when working within systems which are not designed to incorporate diverse understandings and care models. Studies have shown that people heal best when connected to supports within their home communities. In Newfoundland and Labrador, and across Canada, the numbers of youth experiencing increasingly complex and intersecting needs is on the rise. ⁴ They are struggling to access care, which is siloed and inaccessible, as per Weins et al. ¹⁸ However, for youth in this province, to access healthcare too often means leaving their support network and travel to St. John’s. This is often hundreds, or thousands, of kilometres away from home. They travel into a metropolitan area seeking help, but get lost in gaps, struggle to find affordable housing, and remain on lengthy waitlists. This increases the struggle to access care from services that are fragmented, according to Government of Newfoundland and Labrador. ¹⁸ Among youth in Newfoundland and Labrador who identified the need for mental healthcare, 40% indicated their needs were either partially met or unmet—Statistics Canada. ¹⁴ While these numbers are not specific to Indigenous youth, consider that the Indigenous-identified population of Newfoundland and Labrador is 9.3%, ¹³ one can correlate that a large number of Indigenous youth do not have access to appropriate mental healthcare, face systemic barriers to accessing care, and are forced to leave their home communities to have an opportunity to possibly receive care. What is more, the persistence of mental health and substance misuse concerns into adulthood lead to poorer health outcomes, which in turn worsens social and economic outcomes by compounding pre-existing personal, family, and societal challenges.^5,19 The relating costs to exacerbated conditions not addressed in a timely manner create increasing financial and social pressures on healthcare and social systems which are already strained. Simply put, it is far better for individuals to receive appropriate care at a young age, allowing them to achieve better overall health outcomes and reducing long-term strain on limited systems. 87.2% of Indigenous people live off-reserve in Newfoundland and Labrador, ¹³ which greatly reduces access to traditional healing practices available through federally funded programs designated for on-reserve communities. ⁵

Almost 87% of Indigenous people live in small or rural communities. ¹³ Accessing services based in large population centres has financial and geographic barriers. Proponents of virtual care too often do not consider that many of these small and rural communities do not have access to internet or cellular services, technology, or resources. Through offering virtual services, while not addressing the systemic inequality issues of lack of infrastructure to support these services, the gap of health equity for Indigenous youth comparative to non-Indigenous youth is steadily widening. Added complexity is layered, as one must also consider Indigenous youth living within urban communities as having their own distinct communities. Further to this, virtual services are a stop-gap as they provide communication but lack connection. There is no one specific solution which will meet the needs of all Indigenous youth in the province.

Despite having the greatest level of need, youth have the worst access to timely and quality healthcare, and particularly mental health and substance use care, says McGorry et al. ¹⁰ The deteriorating mental health outcomes of youth were further intensified by the COVID-19 pandemic, ³ as across the globe, rates of anxiety and depression in children and adolescents have almost doubled. To provide specific local context, a Choices for Youth evaluation with youth across Newfoundland and Labrador in 2020 revealed that 67% of youth felt their mental health had been negatively affected by COVID-19. Moreover, specific populations, including racialized, newcomer, 2SLGBTQIA+, and Indigenous youth, are more likely to experience poorer mental health outcomes, related to health and social inequities, and often report experiencing significant barriers in accessing safe and appropriate services. It is interesting to note the overrepresentation of Indigenous youth reporting of poor mental health outcomes in this study. Of the 67%, 35% identified as Indigenous. ⁶ In fact, in a follow-up internal survey, held in 2022, Choices for Youth found that the percentage of youth reporting poor mental health had risen to 72%. ¹² As the ramifications of social isolation progressed, youth were less likely to feel supported and expressed a lack of hope for the future. As institutions insisted that folks get back to a new normal, Indigenous youth struggling with their mental health were left with poorer mental health outcomes, and supportive programming that was available during peak lock-down years was ending due to a shift in funding priorities.

Indigenous youth self-reported a desire to have cultural and land-based activities to help with hope, purpose, meaning, and belonging. Specific responses included:

1. Continue to respect and support them with equal attention as all other youth.

Currently, there is still only one operational Integrated Youth Services hub in Newfoundland and Labrador, meaning that youth must travel into St. John’s to receive direct services to support wellness, which removes them from community and natural supports they may have closer to home.

Where do we go from here? How can community and medical systems help Indigenous youth to use meaningful ways to improve their mental health? How can we create systems of care which can be implemented on a broad scope while also providing nuanced healthcare specific to diverse Indigenous communities and individuals? One step is to reduce silos, encourage engagement across governmental departments, and prevent re-traumatization for individuals seeking supportive healthcare. This is the basis for Integrated Youth Services across Canada and globally. The very premise is that youth with diverse needs can enter a hub, tell their story once, and receive healthcare and wrap around social programming supports which are based on their individual needs, including Indigenous specific needs, with a lens of social determinants of health. Education is healthcare. Food security is healthcare. Culture is healthcare. With an integrated team of staff addressing the various physical, mental, emotional, and spiritual needs of individuals, Integrated Youth Services focuses on prevention of deteriorating health outcomes, creating a need for increased specialized services as people get older. Simply put, by addressing needs early, youth accessing Integrated Youth Services have a higher likelihood of preventing more serious issues from developing later in life.

Using the Integrated Youth Services model as a framework, it’s essential to base services and activities within Indigenous ways of knowing, led by Indigenous people within community. Longstanding colonial systems within the province, such as the foster system, continue to take Indigenous youth out of their communities. The impact is that the youth cannot be aware of their culture and traditional ways to healing. If they are in the St. John’s region, the only specific service provider is First Light Friendship Center. However, as one youth worker expressed:

Service Provider 2: “What does access look like? It’s a big word. Youth have to be aware for it to be accessible. They have to be directly involved.

Service Provider 2 clarified that this is in no way a fault of the First Light organization. Rather, the primary concern is based in the systemic barriers and funding limitations which prevent metro-based youth from accessing traditional supports. Indigenous communities are based in Labrador, as well as rural and remote regions of Newfoundland. Travel costs and distance to St. John’s are a continuous barrier to providing or receiving culturally based care, for youth located in the region. It doesn’t have to be a barrier for those in community, if there are systems in place to encourage reconciliation in healthcare.

Using wise practice means of assessments, such as the Native Wellness Assessment™, helps service providers to provide wholistic supports, and have youth centred in the path of their wellness plan. As stated on the Thunderbird Partnership Foundation web site, ¹⁶ “The Native Wellness Assessment™ tool is the first of its kind to measure how cultural interventions affect a person’s wellness from a whole person and strengths-based view.” Through bringing together the strengths-based view and implementing cultural supports alongside western modalities, Indigenous youth can have an approach to care which addresses their intersectional needs. Etuaptmumk tells us it doesn’t have to be an either/or perspective. A youth can benefit from connecting with a psychiatrist to address specific symptoms and medications which could help. They can also benefit from having more opportunities to participate in land-based activities which promote Hope, Purpose, Meaning, and Belonging. The present gap in healthcare within Newfoundland and Labrador is that these systems are too often seen as distinct and disparate, where in reality they are two pieces of the same circle of wellness.

How can this gap be bridged? The provincial government has begun the process of addressing the wholistic needs of people through the development of Family Care Teams. The policy framework states, “Family Care Teams provide a framework to reorganize and expand on existing community-based health services and to modernize and increase the adaptability and agility of the Newfoundland and Labrador healthcare system.” ⁶ If Newfoundland and Labrador Health Services can engage with Indigenous nations and communities within the province, they have an opportunity to truly transform healthcare in the province, as well as implement reconciliation in healthcare. Adding to this initiative is the ongoing work of Choices for Youth and partnering community groups and agencies across the province to establish the Integrated Youth Services Framework model to develop a network of Integrated Youth Services hubs in rural and remote communities. This is a starting point of meeting Indigenous youth where they are at. For these hubs to be truly effective in meeting the needs of Indigenous youth, the model and leadership must come from the nation and community in which it is located. Simply put, Inuk youth need Inuk leaders. Mi’kmaq youth need Mi’kmaw leaders. Innu youth need Innu leaders.

Etuaptmumk can be used to operationalize traditional Indigenous wellness practices within the overall healthcare system. The Government of Newfoundland and Labrador’s The Way Forward plan, ⁹ Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador, ⁷ alongside Newfoundland and Labrador Western Health A Health Promotion Strategy, ¹⁷ and the Journey of Collaboration report ¹ all reference Feather Carriers for Life Promotion as a specific program to help promote Indigenous health and wellness through systems of care to improve health outcomes for Indigenous people in the province. Through a collaborative project, Western Health Newfoundland and Labrador and Qalipu Mi’kmaq First Nation led the training of Indigenous Identified Newfoundland and Labrador Health Services staff in the western region of Newfoundland, alongside Indigenous community workers, to have them trained through the Thunderbird Partnership Foundation, to become Feather Carriers for Life Promotion. Through the teachings and learnings, participants in the project were able to incorporate Indigenous wellness practices into their work practice. However, much like other initiatives, the funding was project-based, meaning that once it was complete, service providers were left unsupported to be able to implement systems-level change.

As Indigenous people working within clinical and community systems, we can act as a catalyst for change, calling on all levels of government to work in achieving reconciliation in healthcare. One way of doing this within the landscape of varied Indigenous nations in Newfoundland and Labrador is to support Feather Carrier positions in all Family Care Teams in the province. This person can act as the connector between seemingly disparate systems. Indigenous youth have clearly stated that representation matters, cultural connections matter, and they wish to receive health supports which do not create a sense of alterity for them. Family Care Teams are one entrance into a pathway for better health outcomes. Feather Carrier Connectors could act as navigators for youth, to connect them to Integrated Youth Services teams which are led by community, work from a strengths-based perspective and work with each other, to find a path to wellness for each young person who walks through the door.