Re-writing One's Own Job Description

Focusing, as it is meant to do, on child mental health, this special issue of Healthcare Quarterly singles out for attention a distinctive category of concerns that, when viewed through lenses common to many Indigenous peoples, is arguably better left unmarked. That is, attempts to carve up the world in such a way that health concerns centre on matters of the "mind," on the one hand, and on "physical" ill health, on the other, are expressive of a form of self-understanding that is more consonant with the classic dualisms of traditional, "Western," Cartesian thought (e.g., the mental in counter-distinction to the physical; selves set off against societies), and quite out of place in those more holistic frameworks of understanding favoured by many of the world's Indigenous peoples (Chandler 2010). Why such putative cultural differences might make a difference – or at least a difference in what is written here – is that any account of health matters in which Indigenous people might actually recognize themselves requires, as a constitutive condition of its coherence, a kind of radical reframing – a shift in axes that replaces the arguably "false" dichotomy between mental and physical health with something better approximated by the much-overheard and more broadly inclusive notion of personal and community "well-being."

Of course, a preference for understanding things holistically is by no means unique to Indigenous groups. Such holistic concepts similarly mark the "wet edge" of verdant thoughts running through the minds of many contemporary Euro-American intellectuals (Overton 2010). Still, and whoever deserves the credit, out-of-fashion "split narratives" and other such "fundamental" antinomies meant to locate minds and bodies on opposite banks of some unbridgeable divide fit especially awkwardly within the usual course of Indigenous thought. Consequently, and all in the hope that what is said here will have some ring of authenticity to those whose health and well-being are under discussion, all talk about what is or is exclusively "mental" about "mental health," and where individuals leave off and whole cultural communities begin, will be replaced by a different way of imagining – a way in which remarks about the individual and the physical are seen to blend seamlessly into a more relational system of accounting that is simultaneously about the mental and the social.

With or without any serious effort to accommodate a more Indigenous way of framing the problem, any scant five or six pages within which to rehearse the myriad ways in which the psychological well-being of First Nations, Métis and Inuit youth is known to be compromised runs the serious risk of reducing to still another exercise in name-calling – a further rehashing of woes that could only serve to further stigmatize a group about which almost nothing good is ever said. Instead, it is hopefully sufficient, for present purposes, to simply offer up a guild-edged guarantee that, for almost any arbitrarily chosen form of psychopathology one might care to nominate, ample evidence is already in hand demonstrating that, on some running average, Indigenous youth regularly fair more poorly than do their non-Indigenous counterparts.

Why all of this has proven to be so is hardly a mystery. As a generally recognized consequence of past and present government policy and public practice, Canada's Indigenous peoples continue to be poorly housed, inadequately nourished, underemployed and improperly educated. Over and above such more easily documented deprivations, Indigenous groups are also routinely targets of racial prejudice and consistently denied the usual rights of self-determination; their languages and cultural practices are criminalized, and their ways of knowing discounted and turned into a laughing stock. This short list is, of course, only a sampler, and one could easily go on and on, adding further salt to existing wounds, but to what point? Nor are there believable grounds for surprise upon hearing, once again, that those who have been most deeply and permanently scarred by such depravations and mean-spirited practices are the young – not only because they are more defenceless but also because they stand at the end of a long train of traumas all promoting the inter-generational transfer of psychopathology.

An Alternative Agenda

So, where does all of this leave the expectant reader? If "mental health" is not a category of self-understanding common within the Indigenous world, and, even if it were, if further rehearsing the litany of woes common to Indigenous youth threatens to do more harm than good, then what still remains to be usefully said?

Two such prospective things are put on offer here, both of which are thought to have important implications for future policies and practices. The first of these is that it is simply wrongheaded (as well as hurtful and deeply misleading) to go on imagining, as is commonly done, that First Nations, Métis and Inuit youth are all equally at risk of, or already manifest, some disproportionate array of mental health problems. Rather, and as I will be at pains to show, the real truth is that while some modest fraction of Indigenous communities do actually possess more than their "fair" share of childhood psychopathologies, it is equally true that many more do not. That is, strong evidence is already in hand (e.g., Chandler and Lalonde 1998, 2004, 2009; Chandler et al. 2010) demonstrating that health problems in general, and "mental" health problems in particular, are never uniformly distributed across the whole of any roughly assembled collection of Indigenous persons; and that, instead, instances of such difficulties tend to regularly "pile up" in some quarters and not at all in others. Consequently, the practice of rudely aggregating evidence collected in ways that collapse across those important dimensions of cultural differences that divide this Indigenous community from that necessarily produces only imaginary numbers or "actuarial fictions" – summary conclusions that apply to no one in particular and that lack any discernible human meaning. What potential advance in our understanding could possibly accrue, for example, from the revelation that the youth suicide rate for the whole of Canada's more than 600 culturally distinct First Nations bands is five, or 20, or any number of times higher than that of the general population? What, exactly, would we be better prepared to do upon learning that, across the nation, the high-school dropout rate for Indigenous youth is somewhere between 40 and 60%?

The truth is that while youth suicides and school failures (to name only two such common failings) are epidemic in some Indigenous communities, elsewhere many other communities, in still greater numbers, graduate the bulk of their students and suffer no youth suicides at all (Chandler et al. 2010). Perhaps summary figures depicting national averages are of some passing interest to those assigned the task of preparing federal budgets, or still another banner headline, but it remains difficult to see how such empty abstractions could possibly be brought to bear by those concerned with actually solving Indigenous problems in well-being, if and where they occur. In short, I mean to argue here that any enterprise that begins by supposing the existence of some "monolithic indigene," some Aboriginal "everyman" (young or old), whose propensities for disorder are extrapolated using only broad-scale averages – any summary effort to paint all Indigenous persons with the same defamatory brush – amounts to a fool's errand.

What all of this comes down to, then, is the certainty that anything less than a sober commitment to undertaking more fine-grained analyses – analyses that do not ride roughshod over the important dimensions of cultural differences that set Indigenous communities meaningfully apart (Hodgkenson 1990), not simply from the general population, but from one another – can only result in a further squandering of scarce resources; money and talent have been misspent on "solving" problems where they do not exist, while a blind eye has been turned to those real, but scattered, health tragedies that mark some Indigenous communities, but not others.

The second matter to be taken up here is a natural by-product of the first, and is all about "Indigenous knowledge" and how it might be brought to bear. My point here will be to persuade you that Indigenous knowledge is an untapped resource in our efforts to deal with Indigenous health and mental health problems where they occur.

If, in some imaginary world, starkly different from our own, lack of well-being should prove to be distributed uniformly, both within and between Indigenous and non-Indigenous groups, then there would simply be no one to turn to for new insights about how mental health problems might be best avoided or solved. Here in our real world, in our own country, however, nothing like this ordinarily happens. Instead, problems of all sorts tend to be wildly distributed, and, as a matter of "best practices," common sense demands that we regularly and usefully turn research attention to those who are most troubled or most problem free. Who among us is especially "cancer prone" or "cancer free," or otherwise "immune" to some particular virus? We all want to know, and are at pains to discover what, in particular, sets those with and without such problems well apart. The logic of doing just this is so compelling as to require no defence. Oddly, however, it is a logic ordinarily abandoned when it comes to efforts to understand the many problems in well-being that plague young people in Indigenous communities.

On How We Might Have Gone So Wrong

In searching for reasons as to why attention has been so inexplicably turned away from the real variability that characterizes Indigenous communities, a short list of candidate reasons easily pops up. Perhaps first on any such short list is the broad – some would say "universal" or "species wide" (Medin et al. 2010) – tendency to mistakenly imagine that out-group or minority-group members are not only different from "us" but are, otherwise, all as alike as peas in a pod. At least for those of us reared in the West, we are, each of "us," conventionally understood as defined by our own signature uniqueness and, perhaps, the distinctiveness of the groups with which we are identified. By contrast, "they" – those outré minority group members – can scarcely be told apart. Simple xenophobia and a predilection for stereotyping out-group members can, then, offer a partial explanation for our apparent readiness to paint all members of all Indigenous groups with the same undifferentiated but discriminatory brush. What such accounts do not do, however, is offer an explanation for our collective failure to entertain the very possibility that certain especially well-adapted Indigenous persons, or groups, might actually prosper in ways that hold a key to some better understanding of otherwise-seemingly intractable health and mental health problems.

A further and less commonly considered way of understanding the mistaken propensity for imagining that all Indigenous groups stand or fall together, and that there is no utility in examining the relative success with which some of these communities have avoided or overcome serious health problems, is to be found in what appears to be the near impossibility of imagining that at least some Indigenous communities may actually possess real Indigenous knowledge, or competencies, or "best practices" that could be drawn upon, or usefully "'transferred"' to, others who are less fortunate. What makes such prospects unthinkable, I will go on to argue, is that whatever dubious moral leg ordinary colonialist practices have traditionally stood upon tends to be shorn up by the common conviction that whatever Indigenous cultures might claim to know is, by definition, childlike, backward and automatically mistaken and, so, invariably demands the guiding hand of more enlightened Western ways of knowing.

Before having more to say about such forms of "epistemic violence" (Spivack 1985: 126), however, and all in an effort to ground this account in something more concrete and "evidence based," I want to narrow the focus of this discussion by introducing a working case in point – one concerned with youth suicide in British Columbia's more than 200 First Nations communities.

A Case in Point: Community-Level Rates of Suicide in BC Indigenous Youth

In narrowing in on this particular example as a way of illustrating the special burden of mental health problems borne by at least some of Canada's Indigenous youth, it needs to be said that almost any of the usual psychiatric disorders might have served as well. Suicide, although perhaps not a "distinct psychiatric disorder" (Kirmayer et al. 2010: 12), does, nevertheless, have one important advantage over most other contenders, primarily because legal obligations force the keeping of careful records about who are and are not believed to have taken their own life. Consequently, suicides, including those among Indigenous youth, provide potentially richer epidemiological data than do most other mental health problems.

For present purposes it is also interestingly the case that suicide is a tragedy exquisitely engineered to try the patience of any committed, card-carrying Cartesian dualist – anyone wedded to the importance of driving wedges between mental and physical health, or otherwise bent upon treating individuals as though they are somehow separated from the societies of which they are a part. Essentially by definition, suicides implicate both troubled minds and broken bodies. Similarly, and at least since Durkheim (1897/1951), it has been broadly understood that, what at first might appear the loneliest of private acts actually varies dramatically between whole social classes or nation states, and can only be fully understood by drawing upon frameworks of understanding that disrespect all iron-clad divisions between minds and bodies, between individuals and whole cultural communities. As such, suicides cry out to be understood as occupying a space located somewhere between such forced dichotomies, and as more clearly the expression of a collapse in general "well-being" than are many other examples of psychosocial pathology.

For all of these reasons, and for almost two decades, my research colleagues and I have tracked the rates of suicide among BC's First Nations youth (Chandler and Lalonde 1998, 2004, 2009) – not, as is most typically done, only at the provincial level, but for each of British Columbia's more than 200 separate bands and 27 band councils. This hard task was taken up out of the conviction that, given the radical cultural diversity known to characterize BC's Indigenous populations, no single, overarching summary statistic or generic portrait could possibly do. Adding apples and oranges would be a mere misdemeanour compared with the indictable offense of wrongly supposing that the distinctive bands that comprise the province's historically diverse First Nations communities all deserve to be seen as adding up to the same single, seamless, homogenized arithmetic whole. In pursuit of such matters, my research colleagues have generated some 30 books, monographs, articles and chapters, all meant to put the lie to any easy assumption about the interchangeability of Indigenous persons and groups. Two kernel ideas have emerged from these efforts – ideas that have already been hinted at, and that bear directly upon the take-home message of this essay. The first of these (already introduced above) is that all generic claims about the rates of youth suicide in Canada, or any of its provinces, amount to actuarial fictions that do more to confound than enlighten. The second is that evidence already in hand clearly demonstrates that many of BC's First Nations communities clearly possess Indigenous knowledge about how to create a cultural community in which young people find life worth living – knowledge that could be "laterally" transferred to other bands whose rates of youth suicide are heartbreakingly high. What have not yet been adequately brought out, however, are the action and policy implications that follow from these matters of fact. The balance of what follows is given over to a detailing of some of these action implications.

Actuarial Fictions and Other Forms of Stereotypy

Even for a research group such as our own, already committed to the expectation that youth suicide rates would vary from one Indigenous community to the next, our actual results — the radically saw-toothed profiles depicted in Figures 1 and 2 – were not fully anticipated. As can be seen from an inspection of Figure 1, close to half (more precisely 41%) of BC's First Nations bands were found to have experienced no (i.e., zero) youth suicides across the 14-year period for which our data are now complete. In many others, where occasional suicides had occurred, the observed rates were less than, or no different from, those of the general population. In dramatic contrast, other of these communities evidenced suicide rates many hundreds of times the provincial average. Obviously, simply adding up all of these wildly disparate community-level rates could only produce a summary statistic representative of no one in particular.

Click to Enlarge

Click to Enlarge

Concerned that our results might be at least partially owed to the so-called small "n" problem that naturally plagues studies of suicide (or anything else) in restricted populations, we also opted to further aggregate our own data at a slightly higher level of analysis (see Figure 2) by re-examining youth suicide rates, this time at the level of whole "tribal" or "band councils" (administrative groups normally composed of 10 or more otherwise separate, but geographically proximate, historically affiliated and often culturally synchronic tribal groups). Again, even by our unforgiving standard of zero suicides across an entire study period, more than one in five of these more populous band councils did not experienced a single youth suicide, and once again, the general pattern of results was wildly saw-toothed, with some groups showing sharply elevated youth suicide rates.

Given these results, how might anyone with ambitions to mount a suicide prevention program in British Columbia best proceed? Setting aside for the moment what the actual content of any such prevention effort might look like, it seems evident that any such candidate program should, first and foremost, focus attention on those particular communities that actually experience high suicide rates. Naturally enough, there have been "one-off" undertakings, prompted by some rash of suicides in specific Indigenous communities that fit such a targeted model. More broadly, however, in British Columbia, in Canada and around the Indigenous world, there have been building efforts to invent various all-purpose, national or province-wide suicide prevention programs. A comprehensive international survey of both the published and grey literatures pertaining to such effort, commissioned by the First Nations and Inuit Health Branch of Health Canada, has just been released by the Cultural and Mental Health Research Unit of the Department of Psychiatry, Jewish General Hospital – an effort spearheaded by Kirmayer and his colleagues (2010). As far as it is possible to determine, in none of the more than 400 references cited by this working group is there a single instance in which such broad-based prevention programs actually began with the prerequisite surveillance efforts that might have made it possible to specifically target communities with demonstrably higher suicide rates among Indigenous youth. Rather, relying upon overarching national or provincial statistics, plans were made and set in motion to offer up some "one-size-fits-all" intervention strategy intended to fit anyone and everyone. There are, of course, economies of scale and matters of public sentiment that argue for rolling out such unified "plans," but none of this is responsive to the fact that Indigenous communities, otherwise notorious for their uniqueness, not only lend themselves badly to any sort of assembly-line treatment, but, more critically, sometimes do and sometimes do not manifest the problems that prompted the mounting of such suicide prevention strategies in the first place. Current practices notwithstanding, what actually needs to be done already seems simple enough: first determine where suicide rates are heartbreakingly high, and only then deploy one's best preventive efforts specifically to these troubled groups.

All such straightforward marching orders aside, everything so far said still leaves open the question of what any such evidence-based suicide prevention strategy might actually look like.

The Lateral Transfer of Indigenous Knowledge

Having hopefully gotten beyond the broadly shared but unsupported assumption that suicide (or is it alcoholism and poor parenting?) is somehow an endemic feature – perhaps even a racial attribute – of simply being Indigenous, where ought one to turn for fresh insights concerning how youth suicide might be best understood and prevented? The officially authorized answer to this question is, of course, research – a solution strategy likely to work only when the attention of the research community already happens to be focused on the problem at hand. It is not. Instead, most of the energy and most of the resources given over to the problem of suicide among Indigenous people have been less about surveillance and more about prevention – a popular agenda that, nevertheless, threatens to put the cart before the horse.

As it is, many countries with substantial Indigenous populations (e.g., Australia, Canada, New Zealand, the United States and various other circumpolar places) have recently moved to create national suicide prevention strategies, and what Australian Aboriginal psychiatrist Helen Milroy has called substantial "suicide prevention industries" (Kirmayer et al. 2010: 85). While there is, perhaps, much to admire (e.g., high energy expenditures, worlds of good intentions) about many of these attempts to jump ahead to possible solutions to problems not yet well understood, far too little attention has been given over to sorting out what does and does not work.

In their careful review of such prevention programs, Kirmayer and colleagues (2010) reluctantly conclude that there is little or no evidence to suggest that any of these programs do actually work to "prevent" suicides. Those few that do have actionable evaluative components tend to have an educational focus and to base their claims for effectiveness on a reduction of ignorance about suicide, rather than any reduction in the actual incidence of suicide per se. If one further narrows the search by focusing only on that short list of prevention programs that directly target suicides among Indigenous people, or, more narrowly still, among Indigenous youth, then there appears to be no empirical evidence at all showing that such efforts have resulted in fewer deaths.

While still thin on the ground, there do exist other programs of research (including that of my own working group) that have endeavoured to identify various social determinants of suicide among Indigenous youth. Although not manifestly about suicide prevention, what these several research efforts have shown is that First Nations bands that have successfully worked to re-build connections to their own cultural past and have regained some measure of control over their own civic lives do enjoy dramatically reduced rates of youth suicide (Chandler and Lalonde 2009). By demonstrating some of the circumstances associated with lower suicide rates, such findings (while more about causes than cures) do offer some indirect insights into the kinds of rehabilitative efforts that communities might undertake in their own efforts to create the sorts of socio-cultural environments that convince Indigenous youth that life is worth living.

Finally, and perhaps most importantly, it needs to be pointed out that any expectation that real insights into the causes and cures of suicide among Indigenous youth must necessarily await the completion of various government-sponsored initiatives automatically betrays evidence of a lingering residue of neo-colonialist thought – one that, as Fanon has pointed out, "wants everything to come from itself" (1965: 63). That is, once having gotten around to addressing the spectacular burdens of ill health facing certain of Canada's Indigenous communities, the standard way of doing business (what so-called knowledge transfer is routinely taken to mean) ordinarily hinges upon (1) first turning to the research community for novel ideas about the likely causes and consequences of this or that health problem; (2) before then funnelling such "insights" to some centralized "policy" centre (most often in Ottawa or Washington), where program planners fashion various generic intervention strategies; and (3) then uniformly visiting these programs upon often-unwelcoming Indigenous communities. Among the many reasons to speak against such generic, context-insensitive, one-size-fits-all, top-down, trickle-down solution strategies – reasons beyond the facts that they are so often resented and undermined, and otherwise reinforce the presumed positional inferiority of Indigenous communities thought incapable of managing their own affairs – is the fact that such extra-terrestrial, "made in New York City" interventions so rarely seem to work

The alternative to be argued for here – a strategy involving the lateral transfer of Indigenous knowledge – advocates taking an opposite tack that aims to capitalize on the persistence of real Indigenous knowledge already known to be sediment within those communities that have shown themselves to be relatively problem free. To return to our working example of band-level youth suicide rates in British Columbia, it is simply true on its face that those bands that have "zero" youth suicide rates – rates substantially lower than those found in the general population – must also have successfully created a socio-cultural environment within which their own young people consistently choose life over death. No one not otherwise still caught up in some "civilizing mission" (Gandhi 1998: 16) – some neo-colonialist view that automatically brands Indigenous knowledge as necessarily primitive or child-like – could fail to see hopeful prospects in any enterprise meant to support the lateral transfer or sharing of such Indigenous knowledge and cultural practices with other communities where youth suicides remain epidemic. At least in a world in which knowledge transfer is too often taken to mean the use of Western knowledge as a weapon wielded against those who are obligated to suffer it, and where our "best" alternatives seem to be the root and branch transplant of top-down intervention strategies that serve to further marginalize Indigenous voices, new efforts to help broker such transfers of Indigenous knowledge between communities would seem strategies worth investing in. This will not be easy either, but it is at least evidenced based and promises to avoid many of the top-down, made-in-Ottawa strategies now being heavily resourced.

About the Author

Michael Chandler, PhD, is a developmental psychologist in the Department of Psychology at the University of British Columbia, in Vancouver, British Columbia.


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