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Introduction
Persisting colonial relations of power result in the ongoing marginalization of Indigenous perspectives in Canadian society, including within healthcare settings, and contribute to health inequities seen in Canada’s Indigenous populations (Jull ; Giles, 2012). Canada’s colonial history has caused the multigenerational disruption of Indigenous families and communities, as well as the physical, mental, emotional and cultural abuses which have been clearly linked to adverse mental health consequences for Indigenous people (Allan & Smylie, 2015). Canadian legislation has historically prevented Indigenous people from participating in their spiritual traditions, speaking their native languages, and parenting their own children, while current legislation such as the Indian Act (1874, amended in 1985) determines who is recognized as status Indian and promotes government control over education, health and the land of Indigenous peoples. (Lavallée & Poole, 2009). Inextricable relationships between colonialism and racism result in the ongoing prioritization of non-indigenous voices and perspectives nationally and this occurs in direct correlation to the marginalization of Indigenous perspectives (Allan & Smylie, 2015). Indigenous people now experience the worst health outcomes of any population group in Canada, with evidence to show that current statistics underestimate the degree of these disparities (Allan & Smylie, 2015). Yet, despite the “overwhelming social, political, economic, and cultural domination and continual interference from Canadian governments and institutions” Indigenous peoples in Canada have “managed to maintain core aspects of their cultures and begin the process of reclaiming autonomy and self-government” (Poonwassie & Charter, 2001, p.64). The high prevalence of social and health inequities in Indigenous populations, combined with evidence showing the importance of Indigenous self-determination in Canada emphasizes the need for systemic change that supports community-level interventions (Kirmayer, Simpson & Cargo, 2003).

Locating the Researcher

I would like to begin by acknowledging that the land on which I live and study is Treaty 6 territory and a traditional meeting ground for many Indigenous peoples, including the Denesuliné, Cree, Nakota Sioux, and Saulteaux peoples.
Conducting this research prompts me to consider whether, as a White Canadian of Eurosettler descent, I can or should speak towards Indigenous issues in health. The answer to this question is not straightforward. Research about Indigenous peoples that does not include them in the process risks becoming a colonizing force, potentially imposing western beliefs, values and attitudes onto Indigenous issues, or risking further stereotyping (Browne, Smye & Varcoe, 2005; Fellner, 2016). Acknowledging the reality of existing power imbalances, a collaborative model of change has been proposed whereby Indigenous peoples and health researchers work together to identify, analyze and make changes to the existing policies, practices and systems that have historically disadvantaged Indigenous peoples in Canada (Browne, Smye & Varcoe, 2005; Jull & Giles, 2012). Although I undertake the bulk of this research alone, it is under the advisement of an expert in the field who identifies as Indigenous. I have informed this work with Indigenous perspectives, with the intent not to appropriate knowledge, but to remind myself that this is important work to be taken as sacred and respected by me. Guided by Indigenous research ethics of relational accountability, including principles of respect, reciprocity and responsibility (Wilson, 2008), I write about a story that is not my own, but is a part of all of us who live in Canada.
My own story is briefly relevant here, insofar as to inform readers of the personal perspective coming to bear upon this work and to locate myself in the social, political and historical contexts relevant to this topic. I am of Norwegian ancestry; my mother came to Canada from Norway, where her family remains, and my father’s ancestors were also Norwegian, but came to Canada as Eurosettlers several generations ago. I was born and raised in Grande Prairie, Alberta, where I grew up in a politically charged atmosphere as a result of my father being known in our community as a social activist, author and storyteller whose works were highly critical of the status quo. My mother also worked in a journalistic capacity and under their joint influence I developed a critical mind and a love for reading that drew me to study English when I began my post-secondary education. It was there that I was introduced to the field of Postcolonial literature: novels and stories written by survivors of colonization describing the processes of reclaiming identity, home and community. Their stories spoke to me in ways that I could not ignore. Narratives from North America, Africa, the Middle East and Australia repeated themes that pushed my thinking on culture, history, and the present-day relationships between descendants of the colonized and colonizers. Mere theoretical ventures only. As an occupational therapy student being trained towards ‘cultural safety’ I began to ask again what it means to live and work in a post-colonial country, especially in the field of healthcare. For the first time, I asked how my understanding of postcolonial studies could be used to inform my actions in concrete ways that support efforts towards decolonization.

Background

Internationally, occupational therapy associations such as the World Federation of Occupational Therapists’ (WFOT) and the American Occupational Therapy Association (AOTA) have supported incorporating social justice into the provision of healthcare to better serve disadvantaged populations (Murphy, Griffith, Mroz, & Jirikowic, 2017). In a joint position statement on Diversity, the Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO), the Association of Canadian Occupational Therapy University Programs (ACOTUP), the Canadian Association of Occupational Therapists (CAOT), the Canadian Occupational Therapy Foundation (COTF) and the Professional Alliance of Canada (PAC) affirm that “occupational therapy is committed to promoting an equitable Canadian society and to practicing in ways that are accessible, welcoming, meaningful and effective for people from diverse social and cultural backgrounds” (ACOTRO, ACOTUP, CAOT, COTF, & PAC, 2014, para.1). Since the Truth and Reconciliation Commission of Canada completed its reports, occupational therapists have been reflecting on an appropriate collective response (Restall, Gerlach, Valavaara, & Phenix, 2016). Restall, Gerlach, Valavaara and Phenix (2016) state that “addressing the calls to action requires occupational therapists to engage critically with the nature and underlying assumptions of occupational theories and concepts” (p.265). Iwama (2007) suggests that considerations of culture in therapeutic practice should include evaluation of the cultural construction of occupational therapy itself. In the Canadian context, there is a recognized need for occupational therapists to acknowledge the racist ideology towards Indigenous peoples that our political systems are founded upon so that we may critically reflect on our practice (Valvaara, Phenix & Restall, 2017).
In current practice the notion of cultural competence has been criticized for its limited empirical support, its potential for promoting cultural essentialism, its failure to de-centre the therapist’s discipline-specific and larger cultural knowledge, and for its assumption that the cultural competence of the therapist determines the efficacy of therapy, as opposed to therapies that are themselves culturally constituted (Furlong ; Wight, 2011; Wendt ; Gone, 2011). Occupational therapists can only apply culturally safe practices after examining, critiquing and changing the profession’s foundational beliefs that reflect Eurocentric values (Jull & Giles, 2012). CAOT (2011) includes cultural safety in a list of recommendations for occupational therapists within their position statement on aboriginal health. A major problem noted by experts in the field is: “teaching cultural safety is more complex than increasing awareness or learning sensitivity; it involves deepening respect for the full meaning of our history of colonialism, appreciating its impact on the health of Indigenous peoples, and translating this into a process of building relationships” (Guerra & Kurtz, 2017, p.129). The concept of cultural safety emerged from New Zealand when Maori nurse leader Ramsden (1990) pointed to the risks inherent when social problems and health inequities are treated as independent from the colonial context and ongoing inequitable social relations from which they arise. With its roots in postcolonial theory, cultural safety has been applied to assess interactions between Indigenous peoples and colonizers in the contemporary healthcare context (Anderson et al., 2003). Cultural safety is highly significant within the Canadian Indigenous context, and has been gathering considerable attention from scholars, Indigenous advocacy and professional organizations and, in some cases, government institutions (Josewski, 2012). Smye & Browne (2002) assert that cultural safety, when “used to examine the health and social relations and practices that are shaped by dominant organisational, institutional and structural conditions” can become “a vehicle for translating post-colonial concerns into praxis, pushing beyond culturalist approaches to policy” (p.47). Cultural safety has also been conceptualized as an ideal outcome of social and health services in postcolonial contexts (Wesley-Esquimaux & Snowball, 2010).
There is a dearth of literature detailing what comprises culturally safe occupational therapy for Indigenous peoples in Canada, despite the commitment to cultural safety espoused by CAOT (2011) and a growing body of evidence detailing the importance of adopting a culturally safe approach to health care when working with Indigenous populations (Iwama, 2006). Turning to the literature, this report seeks to identify core principles of culturally safe and responsive practice, with a view to advancing the national conversation on the implications of ‘cultural safety’ for occupational therapy practice in Canada.
Theoretical Perspective
This report is informed by a postcolonial theoretical perspective, applied through the analytical framework of cultural safety in health care practice. It is important to note that the ‘post’ in postcolonial does not imply that colonialism is over, but that colonial forces of social and political inequities are being expressed in emergent ways (Browne, Smye & Varcoe, 2005). Postcolonial theories have shaped the background of this report to consider how occupational therapy services for Indigenous peoples in Canada at present reflect the aforementioned inequities. The lens of ‘colonial discourse theory’ made famous by postcolonial theorist Edward Said prompted careful analyses of source material by informing this report with a critical perspective on the insidious relationships between knowledge and power, representations of the “Other” and political maneuvering (Said, 2003). Questions of how colonial authority was originally constructed are relevant to questions of how that authority has been maintained, as well as how it might be deconstructed.
Postcolonial theory also underpinned the interpretation of recommendations for culturally safe practice as represented in the literature. Critical perspectives on postcolonial studies have revealed enduring Eurocentric conceptual and narrative paradigms that effectively ignore the neo-colonial imbalances by placing too much of a focus on historical events (Loomba, 2005). Engaging critically with postcolonial theories in the field of health research requires vigilance, for there is the danger of research in this area representing the imposition of Eurocentric theory onto issues of importance to Indigenous peoples (Browne, Smye & Varcoe, 2005). To mitigate this risk, an adviser on Indigenous content was asked to check the author’s understanding and interpretation of source material.
Methods
Objective
The aim of this study is to identify core principles of culturally safe and responsive practice, with a view to advancing the national conversation on the implications of ‘cultural safety’ for occupational therapy practice in Canada.
Design
The research question guiding this report was developed using a pragmatic approach to complex interventions wherein the research question was clarified through the development of a series of simpler questions that each reflected one aspect of the complex nature of the main question (Petticrew et al., 2015). Then, informed by national webinars provided by the Indigenous Cultural Safety Collaborative (2018) learning series, the research question was further refined and verified by comparison to the national discourse on cultural safety as framed by Indigenous scholars. Similarly, background literature was selected based on being repeatedly referenced by trustworthy sources either in the Indigenous Cultural Safety Collaborative (2018) webinars or in reference lists. Because there is considerable heterogeneity of evidence and methodologies in the articles included in this report, a narrative approach to synthesis was followed (Popay et al., 2006). A narrative synthesis is a method useful for summarising the results of a systematic review when there is a broad focus to the research question, and results are represented through storytelling format (Popay et al., 2006). The story told through a narrative synthesis intends to capture what is already known in relation to the research question but does not necessarily arise from reliable or authoritative knowledge (Popay et al., 2006). As such, there is the distinct potential for bias in a narrative synthesis: both bias in the literature represented and also bias of the researcher who is acting as storyteller (Popay et al., 2006). In the context of this report, attempts were made to reduce the impact of bias by enhancing the transparency of the research process and through the inclusion of a section designed to locate the researcher in the particular temporal, social, historical and personal contexts which come to bear on interpretation and representation of the findings.
A narrative synthesis involves developing a theoretical model and exploring the relationships between data (Popay et al., 2006). Prior to specifying the research question, a background literature review was conducted in order to discover the current state of the body of literature on the topic of decolonization and healthcare. At the earliest stages, crude pen-and-paper techniques of mapping the scope of the review were used to determine a research question that would be both relevant and answerable based on the volume of research available (Popay et al., 2006). Once it was determined that there exists sufficient research on the topic of cultural safety and healthcare practice in Canada to support a synthesis, precise inclusion and exclusion criteria were developed. Using postcolonial theoretical perspectives to frame the question, a working theory was developed of how cultural safety works in Canada and how particular factors such as political organization impact its implementation; this theory guided inclusion criteria and early interpretations of data, in accordance with the framework of a narrative synthesis (Popay et al., 2006). Following this, a circular process of data extraction and study quality appraisal was conducted so that methodological quality was assessed in a process keeping with Indigenous research ethics as outlined by Wilson (2008). Using this circular method, research within the body of literature itself was used to inform the standards of methodological quality used to assess the quality of literature synthesised. Preliminary syntheses of findings were accomplished by first describing evidence from the literature and then through the development of specific and concrete categories which sorted evidence so that it could then be compared and contrasted. Following this, increasingly abstract categories were developed to capture the common features of culturally safe practice as described within the heterogenous source material. No distinctions between warrant and claim in the data are made in this report as following the process of narrative synthesis allows for the presentation of joint warrant-claims (Melendez-Torres, O’Mara-Eves, Thomas, Brunton, Caird & Petticrew, 2017).
Search Strategy
Early search strategies using the term postcolonial yielded no results, while (de)colonization produced confounding results for bacterial colonization on medical databases. Search terms were then formed based on vocabulary most used in healthcare settings: cultural sensitivity, cultural competency, and cultural safety. A systematic search of multiple databases using these terms was conducted applied to occupational therapy practice, and healthcare generally, both internationally and nationally. Database subject headings were exploded, when possible, to capture all narrower and related terms. A hand search of reference lists was also conducted.
The search process retrieved 275 references from all databases with 187 remaining once duplicates were removed. Of the 187 abstracts, 122 were excluded for the following reasons: focus was on defining a problem (n=17), too narrow in scope (n=40), not specific to Indigenous population (n=2), not related to occupational therapy practice (n=9), not related to research question (n=29), not Canadian (n=18), not written in English (n=2), and additional duplicates discovered (n=5). Once the full texts of 65 articles were screened, 60 articles were rejected for the following reasons: too narrow in scope (n=10), not specific to Indigenous population (n=3), focus was on defining a problem (n=8), did not answer research question (n=8), beyond scope of this report (n=1), commentary, editorial or review only (n=5), not Canadian (n=3), critical theory (n=9), not accessible (n=2), not in English (n=1), related to background (n=10). Only 5 articles met all inclusion criteria, and 7 additional sources were included based on advisement from an expert in the field, for a total of 12 articles synthesised.
Refer to Appendix C for a diagram summarizing the results of search strategies used. See Appendix D for complete list of search strategy terms, databases searched and reporting of results.
Selection Criteria
Articles were sought out that honoured the perspective of Indigenous peoples in Canada by conducting research in partnership with Indigenous community members, privileging Indigenous views and beliefs over mainstream views, using strengths-based language and/or by aligning the research ethics with Indigenous ethics in research based on relationality (Wilson, 2008) guided by principles such as respect, reciprocity and responsibility. Articles were included that were also solution-focused, spoke to healthcare service provision in general terms, demonstrated alignment with core principles of cultural safety and were written for any healthcare profession with relevance to occupational therapy (including speech language pathology, nursing, psychology, counseling, social work and medicine). Advisement from an expert on Indigenous content was also taken into account when selecting articles for inclusion.
Articles were excluded when too narrow in scope (applying primarily to a particular diagnosis or practice area only), did not answer the research question, were not related to occupational therapy practice, not written in English, or were not accessible through the University of Alberta databases. Articles that did not have a focus on Canada were also excluded, except in one instance where an article from the United States was included to provide an example of a cultural adaptation to an occupational therapy intervention. Refer to Appendix C for a full summary of reasons for exclusion.
Analysis
Analysis of data occurred over five phases. Preliminary analyses of the data were completed simultaneously with the development of selection criteria and at this stage each work was read three times in a process allowing for cross-comparison of literature being considered for inclusion. After screening full texts for relevancy, an initial reading was conducted to make basic notes on the content of each article. Then, a second reading was done with a postcolonial lens to view critically the content, language and methodologies of each article. A third reading for cross-comparisons of the literature was conducted to develop internally-derived standards for study quality appraisal in alignment with practices of cultural safety in research. Cross-comparisons of the literature relied on strong resources, which were provided by an adviser on Indigenous content, and were used as a benchmark for study quality appraisal in order to ground this report in trustworthy sources.
Once articles were chosen for inclusion through the process described above, a second phase of data extraction began. A process for the development of thematic networks was followed in order to “systematize the extraction of: (i) lowest-order premises evident in the text (Basic Themes); (ii) categories of basic themes grouped together to summarize more abstract principles (Organizing Themes); and (iii) super-ordinate themes encapsulating the principle metaphors in the text as a whole (Global Themes)” (Attride-Stirling, 2001). Represented in a web structure, basic themes are contained at the periphery and the network is developed inwards to eventually deduce a global theme at the centre of the web. Each of the twelve articles chosen for inclusion was read again and then analyzed independently of one another; rough schemas of thematic networks were sketched, and these were compared against one another to analyze commonalities and differences between emerging themes. Following the analytical process of developing thematic networks, data extraction began with the concrete and moved towards increasingly abstract concepts: first basic themes were extracted directly from the content of each work, then organizational themes were developed by organizing basic themes into clusters, and lastly global themes were created in an attempt to encompass the nature of the argument being made (Attride-Stirling, 2001).
Using the thematic networks, the third phase of data analysis involved an integration of data from all source material. Basic themes and organizational themes were compared and contrasted before thematic networks were developed to incorporate data from all sources. In this phase a constant comparison method was followed so that data could be compared to each new piece of information and, simultaneously, be checked against data already organized to allow for sorting into organizational themes (Morehouse & Maykut, 2002). Twelve organizational themes were categorized and grouped together into increasingly broad categories until three global themes were developed.
In the fourth phase of analysis, meaning was derived from global themes and applied by the author in an attempt to understand implications for occupational therapy practice specifically. At this stage, comparisons were made between occupational therapy practice and the practice scenarios described in the literature. The goal of this approach was to produce information relevant to occupational therapy and to inform, where possible, actions of practitioners and governing bodies so that cultural safety may result.
In the fifth and final phase of analysis, a narrative synthesis of data was written to tell a story attempting to answer the simple question: “what does cultural safety look like in practice?”
Findings
While this report relies on the term ‘Indigenous’ to collectively refer to all of Canada’s various First Nations, Métis and Inuit populations, it is intended with respectful recognition of the diversity that exists between and within Indigenous communities. The author wishes to acknowledge the risk of cultural essentialism that exists when making generalizations about the numerous groups that make up the Indigenous population of Canada.
The literature included for synthesis in this report identifies key elements of culturally safe practice in health care settings, as defined by Indigenous people who are providing or accessing services. When selecting articles for synthesis, preference was given to literature that demonstrated an alignment with principles of Indigenous ethics in research. While this body of literature typically does not adhere to all of the same research protocols that are expected in mainstream scientific study, one strength of the body of literature included here is the attention paid to Indigenous conceptualizations of responsible and ethical research. The most common limitation among the included articles was variability in how methods were reported, and whether they were reported at all. However, applying western scientific protocol to Indigenous research would also pose a limitation when the goal is cultural safety; instead, one must rely on consensus in Indigenous communities and among Indigenous researchers for culturally derived protocols for scientific rigour and validity. The literature contained within this synthesis is typically very contextualised and authors often use highly personal styles of writing, rather than adopting the impersonality of wording and methods that western scientific protocol often demands.
Refer to Appendix A for a complete summary of articles synthesised in this report.
The following three core practice principles were developed to explore the features of cultural safety described in the literature, at a more abstract level, in a way that captures the heterogenous source material.
Contextualised Practice (Not Universal Practice)
Authors routinely cited the need for contextualised services that are situated geographically, temporally, historically and culturally. It is important to remember that Indigenous identities are not determined by genetics but are shaped by ways of life that themselves may be influenced by realities of historical, political and social influences (Kirmayer, Simpson ; Cargo, 2003). Based on a synthesis of the literature, a culturally safe approach to occupational therapy practice would be a contextualised one that takes into account the impacts of the social, historical, political, personal and geographic contexts of both client and therapist. Framed within the Canadian Model of Occupational Performance and Engagement (CMOP-E) (Townsend ; Polatajko, 2007), cultural safety in occupational therapy depends on the therapist’s ability to understand how particular social, cultural, institutional and physical environmental factors influence client, therapist and the therapeutic relationship, and upon the therapist’s ability to tailor services in a way that is responsive to these factors.
Flexibility of service provision was cited as one way to be responsive to the needs of Indigenous communities, including flexible professional codes of ethics that can adjust to community ethics (Fellner, 2016). The question of flexibility in the application of occupational therapy codes of ethics will be important to the national dialog on cultural safety. In occupational therapy practice, responsive flexibility might also mean working atypical hours such as in evenings or on weekends, conducting therapy in unusual environments such as outdoors, or adapting the goals of therapy to meet the goals of the larger community as well as of the individual client. An emphasis on the importance of community among Indigenous cultures was repeated throughout the literature, and several authors identified a need for health services that are shaped by community needs and goals, rather than by routines and processes which offer essentially the same kind of service to all communities. The central importance of collectivism to Indigenous cultures was repeatedly expressed in the literature. According to Wihak ; Merali (2003), the Inuit principle of Pijitsirniq emphasizes the need to serve one’s community through a focus on group (vs individual) needs and goals and it was argued that the counseling process should be modified to respect potential value differences by asking about and listening for the client’s collective narrative and collaboratively setting therapy goals that are consistent with group or community goals. Being community-centred was defined by Zeidler (2011) as a collaborative process wherein a professional consults with the community before responding to a need. An example of this in practice provided by Fellner (2016) is the idea of organizations hosting regular forums to gather feedback that will help them to continually evaluate and adjust services to address community needs and desires as they arise. The key to understanding the principle of community-centeredness, as it is represented in the literature, is appreciating the locality of community and the great variations in strengths and challenges that exist between communities. For occupational therapists, being community-centred will require the development of therapeutic rapport on a larger scale and cultivating an appreciation for community goals in addition to individual client goals. Community was also described by one source as the “primary locus of injury and the source of restoration and renewal”, and it was claimed that when the collective is devalued then individual wounds result (Kirmayer, Simpson ; Cargo, 2003, p.21). Collective identity here is understood as being “created out of interactions with a larger cultural surround, which may impose disvalued identities and marginalised status” upon Indigenous peoples (Kirmayer, Simpson ; Cargo, 2003, p.21). With their focus on a holistic understanding of mental health, Lavallée ; Poole (2009) state that “to understand how to heal the individual and collective identity of Indigenous Peoples we need to explore the colonial impact on identity” as the foundation of ill health (p.275).
Several of the sources made explicit the need for providing healthcare that is informed by an understanding of the complex nature of intergenerational trauma when working with Indigenous individuals (Linklater, 2014; Browne et al., 2016; Kirmayer, Simpson ; Cargo, 2003; Fellner, 2016). Browne et al. (2016) argue that “dispossession from Indigenous lands, territories, cultures and languages is a fundamental determinant of health and form of structural violence that is often at the root of people’s mental health and substance use issues” (p. 11). Further, recent public discourse around Canada’s history of residential schools has brought to the forefront discussions around trauma and locates current individual problems in a shared past; the implication of this for health service providers is that, in discussions with clients, clinicians should “avoid ‘psychologising’ what are fundamentally political issues” (Kirmayer, Simpson & Cargo, 2003, p.20). Ceremonies specifically intended to address trauma were recommended by participants of the Fellner study (2016) and a potential function of culturally safe occupational therapy could be the enablement of ceremonies as occupation. In her book Decolonizing Trauma Work (2014), Linklater provides numerous examples of therapeutic practices that depend on Indigenous approaches to promote healing from trauma. Kirmayer, Simpson & Cargo (2003), meanwhile, urge caution because placing too much of a focus on historical colonial traumas effectively ignores the reality of systemic practices that continue to marginalize Indigenous peoples and may overshadow other dimensions of experience that negatively impact health and well-being. This means that occupational therapists who wish to address colonial trauma in practice should do so with caution. Nonetheless, understanding individuals as being influenced by the historic colonial forces that have impacted whole families and communities is consistent with Indigenous worldviews that define the individual by a “web of relationships, that includes not only extended family, kin and clan but, for hunters and other people living off the land, animals, elements of the natural world, spirits and ancestors” (Kirmayer, Simpson & Cargo, 2003, p.18). Given this, one move towards culturally safe practice in occupational therapy could be an expansion of our understandings of ‘environment’ as denoted in the CMOP-E (Townsend & Polatajko, 2007), to incorporate Indigenous conceptualizations and thereby broaden our definitions.
Authors also discussed the need to situate practice in the current social and political climate. For example: due to the over-representation of Indigenous children in foster care, Zeidler (2011) points out that “families may become more comfortable accessing services when professionals clearly and explicitly communicate their purpose” (Zeidler, 2011, p.140). In occupational therapy practice, this will include a clear and comprehensible explanation of what occupational therapy is, the purpose of the visit, how information will be used, and a comprehensive description of limits to promised confidentiality. To accommodate for the power differentials that exist between therapist and client, Zeidler (2011) also recommends scheduling visits in neutral, safe places that are comfortable for the client. Poonwassie & Charter (2001) express shifting power dynamics by asserting that therapists working with Indigenous peoples “must critically examine their role as experts” and accept worldviews other than their own in order to facilitate empowerment (p.70). However, all authors acknowledged the limitations of individual efforts due to systemic barriers, and one author summarized this tension this way: “No matter how open and unbiased practitioners try to be, they work against a backdrop of structural violence, racism and marginalisation” (Kirmayer, Simpson & Cargo, 2003, p.21). One participant in the Fellner (2016) study made the point that having Indigenous-specific specialized services available is good, but that making all services accessible and relevant to Indigenous clients and Indigenous practitioners would be much better. Browne et al. (2016) assert that this process should be implemented through partnerships that involve clinicians, clients and the community. They also argue that, in order to avoid the appropriation of knowledge, forming local committees that include trusted community members, such as elders, who can act as advisors may be essential to this process in some settings (Browne et al., 2016). Maar et al. (2009) and Fellner (2016) observed that funding for elders and ceremony is often short term, inadequate or constrained by jurisdictional issues. All three of these articles argued that there is a need for the health care systems to support Elders and Ceremony financially (Brown et al., 2016; Maar et al., 2009; Fellner, 2016). In order to engage in culturally safe practice, occupational therapists may first need to advocate for funding to support the integration of elders, healers and ceremony into mainstream health services. Working with elders and Indigenous healers as part of a multidisciplinary team is one possible vision of culturally safe practice and, furthermore, promotes social justice and health equity in circumstances where Indigenous views on healing have long been marginalized.
The Government of Nunavut is the first and only public government in Canada to be shaped and led by an Indigenous worldview (Wihak & Merali, 2003; Kirmayer, Simpson & Cargo, 2003). According to one source, healing from colonization involves re-asserting cultural autonomy and reinstating cultural traditions through the establishment of self-government and legal claims to traditional lands (Kirmayer, Simpson & Cargo, 2003). Similarly, one article stated that a “key aspect in decolonization is empowerment,” and this occurs through access to and control of personal, organizational and community resources (Poonwassie & Charter, 2001, p.69). In order to promote local control over determinants of health for Indigenous communities, one researcher pointed out that the risk of suicide in individual Indigenous communities has been found to be strongly negatively correlated with the level of control each community has over factors such as education, health services, cultural facilities, self-government and more (Kirmayer, Simpson & Cargo, 2003). Wesley-Esquimaux & Snowball (2010) call for honesty between Indigenous peoples and the government, because “if a community does not believe in the services they are being offered, or perceives they cannot be changed even when they want them to reflect their own needs, a breach of honesty has occurred on both sides of the relationship” (p.399). Pursuing this theme, culturally safe occupational therapy practices might be developed through honest communication with Indigenous communities in order to discover how occupational therapy can respond to the specific needs of a community in a way that is relevant and meaningful.
Wise Practice (not Best Practice)
Synthesis of the literature revealed a need to critically consider the implications of relying on a ‘best practice’ framework to guide occupational therapy practice. Wise practices represent an alternative model of thinking about how to guide therapy in a way that results in maximum benefit for the client. Due to processes of colonialism, including practices of forced assimilation such as residential schooling, the sacred teachings of many Indigenous groups have not been disseminated widely among the people for some time (Wesley-Esquimaux & Snowball, 2010). Yet despite this, all authors included in this study described traditional ways of healing that are still practised by Indigenous individuals and communities, and Indigenous identity was acknowledged by one author as a source of resilience (Kirmayer, Simpson & Cargo, 2003). All authors spoke to the concept of using Indigenous wisdoms and knowledges to guide clinical practice, but one author spoke specifically to a “wise practices model” originally introduced through the Canadian Aboriginal Aids Network (Wesley-Esquimaux & Snowball, 2010). As a lens applied to clinical practice, Wesley-Esquimaux & Snowball (2010) claim that wise practices “are immediately available because they begin from a position of internally generated cultural appropriateness and are tailored to suit the capacity building and cohesion needs of each individual community based on their common understandings and historic practices” (p.394). More than just a lens, Wesley-Esquimaux & Snowball (2010) position wise practices as an alternative to best practices, asserting there is “plenty of ‘evidence-based’ knowledge to substantiate the wisdom of applying traditional values and practice” (p.393). The foundations of the wise practices model are the ‘Grandfather Teachings’ or ‘The Seven Sacred Values’ of courage, honesty, humility, respect, truth, love, and wisdom, representing a journey of collective growth through the embodiment of these seven qualities that result in a good and balanced life (Wesley-Esquimaux & Snowball, 2010). The concept of a balanced life leading to good health for the client and effective practice for the therapist was repeated through the literature (Lavallée & Poole, 2009; McCormick, 1996; Fellner, 2016). More than offering suggestions of how to alter therapeutic practice, the literature emphasised how a therapist’s ways of living, being and thinking impact their ability to engage in culturally safe practice. According to Fellner (2016) participants in her study talked about how an ‘all my relations’ framework centred in Indigenous knowledges can involve “case conceptualization and treatment that is collective, intergenerational, spirit-centred, land-based, survivance/resilience/strength-based, client-centred, holistic, community based and ceremonial” and depends upon clinicians themselves living in a good way so they may draw on personal resources to assist in their work (p.328).
All authors deemed it important for clinicians to respect aspects of Indigenous culture that differ from mainstream Canadian culture, but each author identified slightly different examples of this. According to McCormick (1996) a “lack of knowledge of First Nations values, belief systems and world view can, for example, lead to faulty assumptions concerning the diagnosis of the problem, and the strategy used in solving the problem” (p.164). Wihak ; Merali (2003), with their focus on Nunavut, ask practitioners to acknowledge that client support networks tend to include non-biological relatives and they relay the importance of enabling individuals to resume roles that support the functions of the group. This last point has significance for culturally safe occupational therapy, which might in some circumstances involve a focus on enabling the functioning of a group as a whole. In Inuit society, decisions are made by all members of the community using a collaborative problem-solving approach; translated to clinical practice, this means that clinicians should refrain from using a highly directive approach (Wihak ; Merali, 2003). In Nunavut, it is understood that valuing knowledge gained through observation and experience, intuitive awareness, respect for the wisdom of Elders, and Pilimmaksarniq (revealed truth) can help clinicians design interventions that draw on clients’ knowledge (Wihak & Merali, 2003). The participants of another study discussed the importance of care providers coming to understand Indigenous worldviews and values through culturally relevant training and cultural practices written into policy (Fellner, 2016). Along these lines, Poonwassie & Charter (2001) identified clinical practices based on Indigenous cultural imperatives of non-interference, non-competitiveness, desire for harmony within the group, acknowledgment of the wisdom of others, and emotional restraint. When sharing information with clients, applying the principle of non-interference translates into a non-directive, collaborative problem-solving approach that helps the listener to understand how to take responsibility for his/her own actions and allows the client to decide to accept any wisdoms being offered (Poonwassie & Charter, 2001). Outside of specialised services there is an apparent need for Indigenous knowledges and ceremonies to become available in mainstream health care. Fellner (2016) identified a need to change existing policies that act as barriers to the implementation of Indigenous healing strategies such as smudging and sweat lodges, two examples of traditions that have been described as “liabilities” by mainstream organizations. Findings in the Fellner (2016) study also indicated that incorporating Indigenous philosophies resulted in practitioners applying a “de-pathologizing survivance/basic wellness/resilience lens” and “honouring visions and spiritual experiences that may otherwise be labelled as hallucinations or delusions” (p.324).
With great relevance to occupational therapy practice, one author noted that spirituality and healing were traditionally embedded in occupations: Indigenous peoples “had a wide range of methods of healing that were embedded in religious, spiritual and subsistence activities and that served to integrate the community and provide individuals with systems of meaning to make sense of suffering” (Kirmayer, Simpson & Cargo, 2003, p.16). Other authors echoed the spiritual dimension of the environment and the importance of living in harmony through participation in ceremonies such as sundances, medicine lodges, fasts, sweats, smudging, sharing Circles, talking circles, pipe ceremonies, moon ceremonies, give-aways or potlatches (Poonwassie & Charter, 2001; Linklater, 2014; Fellner, 2016). While the CMOP-E (Townsend & Polatajko, 2007) places spirituality at the centre of the person, these findings reveal an alternative view in which all elements of the person, occupation and environment are imbued with spirituality. Drawing upon the power of the land in order to facilitate healing work was identified as important by participants of several of the studies (McCormick, 1996; Fellner, 2016; Linklater, 2014). Fellner (2016) described in concrete terms the kinds of spaces that participants in her study identified as healing spaces; they described spaces that used Indigenous architecture, natural building materials, and provided access to green space and space for spiritually cleansing work during service provision. Future directions for cultural safety in occupational therapy may include the enablement of traditional occupations, the development of land-based therapeutic interventions, and working to provide clients with access to green spaces as well as spaces for ceremony.
Even when considered ‘best practice’, standardised mainstream assessments may not be effective at identifying the spiritual, physical, emotional imbalances that cultural assessments root out (Linklater, 2014). A potential area for further development in occupational therapy is the development of cultural assessments, interventions and practice models relevant to Indigenous worldviews. McCormick (1996) described the means and ends of counselling, as defined by participants in his study, in terms of balance, interconnectedness and transcendence. Interestingly, McCormick (1996) also pointed out that, by dealing with the spiritual aspect of people in counselling, it might be possible that counsellors would become more effective with non-Indigenous clients as well. Regarding culturally appropriate ends of therapy, one author pointed out that “existing outcome indicators are based on clinical approaches in mainstream populations and do not take into account Aboriginal understandings of healing or the multi-generational effects of colonization on mental health” (Maar et al., 2009, p.10). In her book, Linklater (2014) shares the stories of Indigenous healers who are practising decolonized trauma work and who use traditional teachings to help Indigenous people recover from trauma. For example, Darlene Auger of Alberta uses a therapeutic swing in her healing work that resembles a traditional baby swing, decorated by ribbons, with padding that swaddles the person (Linklater, 2014). While traditional methods of healing are not to be appropriated, it is nonetheless interesting that the occupational therapy intervention of swinging could potentially be applied in a way that is relevant and meaningful to Indigenous clients.
Some studies analyzed cultural adaptations to specific mainstream interventions. While group interventions are common in therapeutic practice, several authors supported the intentional transforming of group therapy sessions into teaching, sharing or healing circles based on traditional protocols (Poonwassie & Charter, 2001; Wesley-Esquimaux & Snowball, 2010; Fellner, 2016). When developed in partnership with Indigenous healers and practitioners, cultural adaptations to occupational therapy interventions may result in increasingly culturally relevant practices. A study from the United States introduced a cultural adaptation of trauma-focused cognitive-behavioural therapy that incorporates elements of Indigenous cultures into the gradual exposure process and the teaching of relaxation skills (BigFoot & Schmidt, 2010). For example, taught relaxation skills may include visualizations of “familiar soothing traditional images” such as “the sway of wind-swept grasses or of the movement of a woman’s shawl during a ceremonial dance” (BigFoot & Schmidt, 2010, p.852). The core constructs of this treatment arise from Indigenous worldviews of interconnectedness and the spiritual nature of all things, and the framework for this practice is the circle, with spirituality at the centre and components of the person surrounding (BigFoot & Schmidt, 2010). The component worksheet detailing the framework is included in Appendix B.
Several authors spoke to the importance of developing structured partnerships with elders to support their important role in wholistic healing and to advocate for their fair compensation (Poonwassie & Charter, 2001; Browne et al., 2016; Fellner 2016) On Manitoulin Island in Northern Ontario, the Knaw Chi Ge Win (New Beginnings) team is comprised of “a core of providers with expertise in psychology, mental health nursing, long-term care, social work and traditional Aboriginal medicine and healing” and collaborative practice is “enhanced by integrated specialized services” (Maar et al., 2009, p.4). They use strategies to support integrated cultural approaches such as establishing traditional healing protocols and building capacity in clients and communities (Maar et al., 2009). The Knaw Chi Ge Win team has also developed formal networks to coordinate service providers and to connect Indigenous and mainstream agencies (Maar et al., 2009). All team members explicitly respect clinical as well as traditional service approaches, and the integrated approach to collaborative care allows the team to be responsive to diverse comfort levels that clients have with Indigenous and Non-Indigenous practices and practitioners (Maar et al., 2009). Following their lead, occupational therapists may work to include Indigenous traditional healers as part of the multidisciplinary team, cultivating a personal and professional respect for traditional approaches to facilitate true collaboration.
Personal Practice (Not Impersonal)
Throughout the literature there was a repeated emphasis on the vital importance of a practitioner being able to engage on a personal level with Indigenous clients. Personal qualities of the therapist were deemed as important to the therapeutic process, which is a concept already familiar to occupational therapists who work to develop the intentional therapeutic use of self (Taylor, 2008). It was found to be possible for Non-Indigenous peoples in Canada to learn the skills and develop the personal qualities that support an uplifting therapeutic practice when working with Indigenous people. Zeidler (2011) found that, within the BC community in her study, Indigenous clients wanted professionals who were unbiased, non-judgemental, compassionate, trustworthy, comfortable in silence, and able to set aside their own agenda to connect with community members. Participants in Fellner’s study identified the therapist qualities of warmth, respect, openness, concreteness, and availability as being critical to developing relationships with Indigenous clients (Fellner, 2016). Self-disclosure by the therapist was found by Wihak & Merali (2003) to help achieve credibility, when the therapist was able to use disclosure to demonstrate his/her own wisdoms gained through experiential learning. Participants of the Fellner (2016) study spoke to the potential that therapist self-disclosure has for building trust and strengthening the therapeutic relationship.
In order to engage in culturally safe practice, it appears to be even more important for occupational therapists to develop their therapeutic use of self in a way that communicates openness and acceptance of worldviews different from their own. Clients and providers in Knaw Chi Ge Win generally agreed that culturally appropriate care means providing a safe environment without fear of judgement; “beyond offering traditional healing services” it was found that clients valued “provider acceptance of clients’ beliefs, religions, backgrounds, and history, and a focus on building the strengths of Aboriginal people” (Maar et al., 2009, p.9). Taking this notion further, both Fellner (2016) and Browne et al. (2016) spoke to the need for examining the motivations of both Indigenous and non-Indigenous staff who work with Indigenous clients. Browne et al. (2016) suggested that practitioner values and motives should align with a social justice orientation while Fellner’s (2016) study recommended assessing the motivations of candidates during hiring processes “in order to screen for any intentions that are not in the best interests of the community (e.g., power differentials, romanticizing, saviour mentalities, money, convenience, prejudice)” (p.332). Many of the articles acknowledged the existence of subtle, widespread, anti-Indigenous racism that, at present, interferes with the provision of effective healthcare services for Indigenous peoples in Canada (Browne et al., 2016; Fellner, 2016; Kirmayer, Simpson ; Cargo, 2003; Zeidler, 2011). One article stated that racism in Canada is expressed in overt discrimination based on persisting stereotypes of the ‘drunken Indian’ and ‘savage’, but beyond that there exists an ongoing lack of regard for the lasting impact of colonization on Indigenous peoples (Kirmayer, Simpson ; Cargo, 2003). Participants in one study discussed the personal responsibility of students and clinicians to educate themselves on colonial histories and the personal, collective and intergenerational contexts that implicate all Canadians in the colonial relationship (Fellner, 2016). Zeidler (2011) found that it is not enough for a therapist to merely know the historical and contemporary context, but there is the expectation that “this knowledge will result in a deeper understanding of the difficulties and hardships as well as the successes and achievements that the community and families have experienced” (p.142). For individual practitioners, and for organizations, strategies to combat racism may involve adopting a policy of cultural humility (Kirmayer, Simpson ; Cargo, 2003). Wesley-Esquimaux ; Snowball (2010) state that “Aboriginal people will not be able to find their way through to healing unless they are able to tell their stories in a safe and sacred space” (p.398). Based on the reading of the literature, the way occupational therapists can create a safe and sacred space is by adopting an attitude of cultural humility and cultivating an appreciation for Indigenous experiences and wisdoms.
Linklater (2014) identifies relationships as one significant method of healing through connectedness, and the therapeutic relationship that is formed from an authentic connection may, in and of itself, be a healing force. Relationships with clients, colleagues and the community, especially clinician participation in Indigenous community events, were deemed important to the therapeutic process across studies. Trust was earned by professionals who spent time in the community and let themselves be known as a community member as well as a professional (Wihak ; Merali, 2003; Zeidler, 2011; Fellner, 2016). Community relationships were identified in one study to be important networks that facilitated connecting clients with holistic care services (Fellner, 2016). A few of the articles described how relationships with members of an Indigenous community may be slow to emerge, and for this reason it was deemed important for professionals to develop long-term connections and commitments to both clients and the community (Zeidler, 2011; Fellner, 2016). The importance of the therapeutic relationship was emphasized repeatedly, and Zeidler (2011) even recommended the establishment of an authentic relationship prior to conducting assessments or interventions. In Nunavut, a clinician’s ability to engage in critical ongoing reflection on their own relational styles and their ability to determine the congruence of particular interventions and assessments with a client’s level of cultural identification were deemed important (Wihak ; Merali, 2003).
Discussion
Beyond Cultural Competencies; Re-Thinking Occupational Therapy Services in Canada
The introduction and background of this report present only a small sampling of the vast amounts of research available detailing the ways in which healthcare services have failed to respond to the needs of Indigenous peoples in the wake of colonization. An evolution of understanding has led to a greater awareness among healthcare providers of the need for services that are responsive to colonial circumstances and relevant to Indigenous philosophies of healing. Moreover, the clash between Indigenous and Western Eurosettler worldviews presents a risk of harm to Indigenous peoples who access highly westernized healthcare services. It has become apparent that a narrow focus on teaching individual practitioners a set of skills deemed ‘cultural competencies’ effectively ignores the systemic and institutionalized practices that, at worst, represent racist ideologies and, at best, ethnocentrism. Yet despite the abundance of literature detailing these practices which cause harm, there is a definite lack of information regarding theories, models of practice, assessments and interventions that can be considered culturally relevant to Indigenous peoples.
The implications of the findings of this report for culturally safe occupational therapy practice in Canada are many, but abstract, and the teachings contained within are open to interpretation. Occupational therapists must locate their practice socially, geographically and temporally by learning about the particular histories, cultures and traditions of the people who live in that area. Traditional occupations of Indigenous peoples were imbued with spiritual meaning and held the potential for healing individuals and communities; therefore, the enablement of traditional occupations and roles may be a valuable contribution of occupational therapy. Finally, occupational therapists must critically consider the cultural construction of our foundational models of practice and professional codes of ethics, in order to identify and uproot any practices that may be considered assimilationist, ethnocentric or otherwise harmful to Indigenous peoples. In order to practice effectively, occupational therapists may need to reconsider ‘best practices’ and instead work to understand and apply ‘wise practices’ informed by cultural imperatives. This depends upon a therapist’s ability to practice cultural humility and respect the wisdom of the client.
Further Directions for Research
This report identifies a researchable problem: that the professional bodies of occupational therapy in Canada are advocating ‘cultural safety’, yet it is not entirely clear what this means or how the theory of cultural safety translates into practice guidelines. Future research initiatives are needed to determine, in partnership with the Indigenous communities being served, how occupational therapy services can result in cultural safety and ultimately provide better occupational therapy services to First Nations, Métis, and Inuit peoples in Canada in order to appropriately address community health concerns
Limitations
This report was limited by the constraints of completing this research for the purpose of fulfilling the requirements of my degree. This small-scale narrative synthesis represents only a theoretical venture into an alternative view of therapeutic practice in Canada, one which is contained by my own limited understandings and worldviews.

Conclusion
In Canada, occupational therapy espouses a commitment to providing services that are meaningful and relevant to clients from diverse cultural backgrounds, but there has been debate about whether these services are culturally safe for Indigenous peoples, given a history of colonization and a depth of research available detailing current health inequities between Indigenous and non-Indigenous populations. The findings of this report describe, in general terms, differences that have been observed in practice between mainstream healthcare and specialized services that work within models of healing that respond to the specific needs of the population and align with Indigenous values, beliefs and traditions. While this report included sources from various fields of healthcare, its focus was on occupational therapy and there are many implications of the data that are highly relevant to occupational therapy practice. Findings revealed three main abstract categorizations that altogether represent a paradigm shift in the way we think about pathology, wellness, evidence-based practice and our role as therapists.?
Acknowledgments
The author wishes to thank Dr. David McConnell for his valued advisement on this project, which always led to greater clarity and improved vigour.
The author also gratefully acknowledges the advisement of Dr. Karlee Fellner, whose input on the interpretation of Indigenous content was invaluable to this process, and whose own dissertation provided the original inspiration for this research project.
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