Evaluating the Integration of Indigenous Healing With Principals of Seeking Safety for Treatment of Indigenous Patients With a History of Trauma and Active Substance Use Disorder.

Background:

Indigenous Ways of Knowing coupled with Indigenous Healing provide the foundation for achieving personal and community wellness. Specific health outcomes experienced by Canada's Indigenous Peoples- including trauma and substance use disorders (SUD)-are seen as a direct consequence of colonization. Most notably, these effects are seen in the multi-generational trauma of the residential school system (Kirmayer, et al., 2009; Menzies, 2014; Thatcher, 2004; Stewart, 2008). The aspiration of healing and wellness is most effectively achieved by using tools and methods that are both appropriate and effective for Indigenous Peoples and communities. The evidence suggests that one of the key consequences of the colonial influence on Canada's Indigenous Peoples has been intergenerational trauma, and high rates of depression, suicide, and SUD (Bombay, Matheson, & Anisman, 2009; Kirmayer, et al., 2000; Haskell & Randall, 2009). Intergenerational trauma is the most common term used to describe the systematic trauma suffered by Indigenous Peoples (Evans-Campbell, 2008; Haskell, 2009; Palacios & Portillo, 2009). Intergenerational trauma is now seen as a precursor to depression, anxiety, post-traumatic stress disorder, re-enactment of trauma, suicide, and SUD (Brave Heart, 2004; Duran, 2006; Menzies, 2014; Thatcher, 2004; Waldram, 2006). Indigenous communities in Canada face significant challenges with intergenerational trauma, which often manifest in SUD. Indigenous communities have identified SUD as one of their greatest health challenges, with some Northern Ontario First Nations communities experiencing SUD rates of 70% (Calveson 2010). Between 2004 and 2009, the number of Indigenous patients seeking treatment for SUD in Ontario increased threefold (Calverson 2010). In 2009, the Nishnawbe Aski Nation declared a state of emergency for prescription drug abuse (Prescription Drug Backgrounder; NAN, 2009), and the number of people seeking treatment continues to rise. Many Elders, traditional healers, and Indigenous scholars agree that connecting treatment to culture, land, community, and spiritual practices is a pathway to healing trauma and SUD for Indigenous Peoples. To address SUD for Indigenous patients, Mamaweswen, The North Shore Tribal Council operate the Benbowopka Treatment Centre. Benbowopka is a residential treatment site in Blind River, Ontario with a mandate to provide treatment for Indigenous patients with trauma and SUD. Historically, the treatment program at Benbowopka merged Indigenous Healing with an abstinence-based residential treatment model. However, a 2015 program review identified the need to modernize the program to address the increasing number of patients with concurrent trauma and SUD. The skills required to heal from intergenerational trauma and subsequent recovery of identity can be enhanced by cultural practices, Indigenous Healing, the presence of Elders, and through traditional ceremony (Duran, 2006; Menzies, 2014; Thatcher, 2004; Waldram, 2006). Similarly, Seeking Safety (SS) is a validated, manualized psycho-educational counseling program that targets the unique problems resulting from SUD and trauma (Najavits, 2009). Importantly, the perspective of SS is convergent with traditional Indigenous Healing methods. Because of the content and delivery method of SS, the program complements traditional teachings such as holism, relational connection, spirituality, cultural presence, honesty, and respect (Gone, 2008; Lavallée, 2008; Menzies, 2014; Marsh et al., 2016). Benbowopka staff work with the Client's Circle of Care Team to develop the necessary support services to address the client's physical, mental health/addictions and cultural needs as part of their aftercare services once discharged. In 2016, Benbowopka worked with Dr. Teresa Marsh to integrate and implement SS into a novel treatment intervention, known as Indigenous Healing and Seeking Safety (IHSS) (Marsh et al., 2015; Marsh et al., 2016a; Marsh et al., 2016b). The IHSS intervention aims to increase the coping skills of participants and reduce the chance of relapse by emphasizing values such as respect, care, integration, and healing of self (Najavits, 2007). This community-led initiative-with a novel IHSS clinical treatment framework-presents a unique opportunity to study innovative approaches to Indigenous wellness.

Indigenous Healing and Seeking Safety (IHSS) Intervention: Initial 90-minute meetings will be conducted with the participants; during these meetings, participants will receive information about IHSS, traditional healing, sharing circles, sweat lodge ceremonies, and program details. The sharing circles will take place at Benbowopka Residential treatment Centre in Blind River, Ontario. Each of the sharing circles will be cofacilitated by two Indigenous health-care workers. These facilitators will organize and lead sharing circles daily throughout the 28-day treatment cycle. Each sharing circle will be two hours long. The Seeking Safety program consists of up to 25 treatment topics that aim to teach participants a variety of skills. The majority of topics address the cognitive, behavioral, interpersonal, and case management needs of persons with SUD and posttraumatic stress disorders (PTSD) (Najavits, 2002a). To adhere to the concept of Two-Eyed Seeing and cultural sensitivity, the material will be conveyed verbally. The facilitators will encourage a language that respects the participants' cultural values and beliefs. To encourage a holistic view of mental health and substance use (which includes connection to community), Indigenous healing practices will be incorporated into the sharing circles. Each sharing circle will be opened and closed with smudging, ceremonial drumming, and singing. Tobacco-a herb recognized in Indigenous culture for its healing powers-will be prepared in bundles in advance of the sharing circles. It will be offered to each participant for protection and healing. The cultural coordinator and facilitators will introduce their sacred items and sacred bundle during the sharing circles. A sacred bundle can consist of one or many items. It can be a tobacco or sacred medicine pouch worn around the neck, or it can be an item such as a sacred pipe that the spirits have given to a person to carry for the people. The sacred bundle is considered a very precious possession that represents a person's spiritual life (Hart, 2010; Menzies, 2010). The participants will be invited to bring their bundles, and will be encouraged to place their sacred bundles or items at the center of the circle. Participants will also partake in at least three sweat lodge ceremonies held once a week during the four-week cycle of the intervention period. Sweat lodge ceremonies will provide a powerful way to bring forth Two-Eyed Seeing as an Indigenous decolonizing methodology. The sweat ceremonies help repair the damage done to the spirits, minds, and bodies of the participants. During the sweat ceremonies, the cultural coordinator will give teachings about Aboriginal traditional healing and its restorative power. Participants will also be invited to share their stories and experiences. Also, participants will attend at least two Sacred Fire ceremonies with the staff and cultural coordinator with the purpose of helping them let go of past traumas and substances. Mamaweswen North Shore Community Health Services currently provides a range of physical and mental health/addictions pre-treatment and aftercare services to the seven Member First Nation communities in our area. Each First Nation community in our area also provides some pre-treatment and aftercare services. All of these services work closely with Benbowopka Treatment Centre around the referral and transitioning of clients between required mental health and addiction services. Mamaweswen North Shore Community Health Services has continued on with its community opiate withdrawal program on Sagamok Anishnawbek and has now established an additional partnership with the Sault Ste. Marie Indian Friendship Centre to offer community opiate withdrawal to First Nation individuals who are living in Sault Ste. Marie.

Objective: This proposal aims to evaluate the effectiveness of the treatment model Indigenous Healing and Seeking Safety (IHSS) for the treatment of Indigenous patients with a history of trauma and SUD. Study findings will be used to inform trauma and SUD residential treatment programming and implementation for Indigenous communities across Canada. Our work will contribute to the field of community-based trauma and addiction programming by addressing objectives that consider:

i) the patient perspective; does patient satisfaction improve when IHSS methodology for treatment of trauma and SUD replaces an abstinence-focused approach? ii) the program perspective; do program completion rates improve following the implementation of IHSS intervention? iii) the community perspective; do health system outcomes in the year following treatment completion decrease following IHSS implementation?