Sharing Knowledge – Moving Forward

Summary Report of the Circumpolar Mental Wellness Symposium

March 25-27, 2015
Iqaluit, Nunavut, Canada

Table of Contents

• Executive Summary
• Introduction
  • Background and Context
  • Overview of the 2015 Circumpolar Mental Wellness Symposium
• Mental Wellness and Resilience in Circumpolar Communities
• Research on Promising Practices
  • Case Studies
  • Literature Review and Community Engagement
  • Discussion
• Research and Policy Perspectives
  • Research that Creates Knowledge
  • Policy that Enables Change
  • Discussion
• Indigenous Youth and Community Perspectives
  • Youth Leadership
  • Community Solutions
  • Discussion
• Key Principles and Lessons
  • Systems
  • Interventions
  • Community Capacity
  • Policy
  • Research
• The Way Forward
• Conclusion
• Appendix A – Selected Bibliography
• Appendix B – Chronology of Circumpolar Mental Wellness Events
• Appendix C – Promising Practices Case Studies
• Appendix D – Symposium Program
• Appendix E – Symposium Participant List

Acknowledgments

For their dedication of time and resources to the Mental Wellness Project over many months, we would like to thank participants from the following organizations:

• International Steering Committee for The Evidence-Base for Promoting Mental Wellness and Resilience to Address Suicide in Circumpolar Communities project, with members from Canada, the Kingdom of Denmark (Greenland), Norway, the Russian Federation, the United States and the Inuit Circumpolar Council;
• Mental Wellness Symposium Planning Committee, with members from the Inuit Circumpolar Council; the Government of Nunavut (Department of Health, Department of Executive and Intergovernmental Affairs); the Government of Canada (Aboriginal Affairs and Northern Development Canada, Canadian Institutes of Health Research, Health Canada, Department of Foreign Affairs, Trade and Development, Public Health Agency of Canada); and Nunavut Tunngavik Inc.; and
• Youth Forum Planning Committee in Iqaluit, Nunavut.

Special thanks and appreciation to the following:

• The Canadian Institutes of Health Research for funding of the mental wellness research projects through the Pathways to Health Equity of Aboriginal Peoples’ initiative, as well as overall coordination and planning for the Symposium;
• The Major Events Management Office, Department of Foreign Affairs, Trade and Development for meeting logistics and support;
• Simona Arnatsiaq, John Duff, Rhoda Kayakjuak, André Moreau, Suzie Napayok-Short and Pierre Trudel for simultaneous meeting interpretation;
• Aboriginal Affairs and Northern Development Canada, Department of Foreign Affairs, Trade and Development and Government of Nunavut for translation of Symposium documents;
• CIHR Institute of Aboriginal Peoples’ Health for youth travel awards;
• CIHR communications staff for video testimonials and media coverage;
• The Public Health Agency of Canada for the Symposium report; and
• Bell Canada for participant travel support.
• Dianne Kinnon for writing and preparing this report.

And for their leadership and support within the Arctic Council for the mental wellness and resilience research project and knowledge sharing Symposium:

• Senior Arctic Officials (SAOs);
• Sustainable Development Working Group (SDWG); and
• Arctic Human Health Expert Group (AHHEG).

Executive Summary

This report summarizes results from an Arctic Council Canadian Chairmanship initiative to promote mental wellness and resilience in circumpolar communities. Sponsored by the Arctic Council’s Sustainable Development Working Group, and funded by the Canadian Institutes of Health Research, two international research teams identified promising practices through a literature review, six intervention case studies and a community consultation process in 2014. These results were published in the report Sharing Hope: Circumpolar Perspectives on Promising Practices for Promoting Mental Wellness and Resilience.

Then, in March 2015, over 100 youth, researchers, representatives from Arctic Council Member States and Permanent Participants^{Footnote 1}, Indigenous organizations and circumpolar communities met in Iqaluit, Nunavut to discuss the research findings and further share knowledge and insights into what is needed and what is working to promote mental wellness and prevent suicide in the Circumpolar region. The thoughtful presentations, personal stories and rich discussion at the 2 ½ day Circumpolar Mental Wellness Symposium led to the following key principles and lessons for moving forward.

Systems

1. Work within an equity model – Target strategies, funding, policies, programs and services to the specific needs and realities of Indigenous Peoples with the aim of creating equity with non-Indigenous populations.
2. Continuum of services – Ensure that communities have access to the full range of programs and services for the promotion of mental wellness and the treatment of mental illnesses.
3. Address social determinants of health – Include the multiple factors affecting mental wellness, such as economic conditions, access to education, poverty, trauma, cultural dislocation, etc. in solutions.
4. Integration – Deliver mental wellness promotion and suicide prevention within existing structures, programs and services whenever possible.
5. Collaboration – Develop knowledge and skills that support collaboration, and enable sectors, disciplines, governments and Indigenous organizations to work effectively together.

Interventions

6. Land-based and other culture-specific programs – Fund interventions that foster cultural continuity and pride, land-based skills, increased access to harvested food, inter-generational relationships, and re-engagement with the community.
7. Focus on children and youth – Integrate mental wellness promoting content and activities for children and youth throughout education, recreation, health, family services and community programs.
8. Indigenous training and program delivery – Whenever possible, train and support local Indigenous people to deliver mental wellness services and programs.
9. Strengths-based approaches – Create interventions that promote responsibility, control over one’s life and the skills to manage challenges.
10. Adapt interventions to specific contexts – Ensure that promising practices are appropriate to geographic, cultural, and community contexts.

Community Capacity

11. Traditional knowledge – Develop ways to preserve and use traditional knowledge, healing practices and Elder teachings related to mental wellness and resilience.
12. Training – Deliver training for service providers, community leaders, families and individuals in promoting mental wellness and reducing suicide.
13. Intervention tools for people at risk – Develop knowledge and tools to strengthen interventions among at-risk populations.
14. Opportunities to share knowledge – Continue to create face-to-face as well as virtual forums to share knowledge and insights.
15. Youth leadership – Provide practical support, capacity development and leadership training to young leaders and youth organizations.

Policy

16. Broad strategies rather than individual policies and programs – Create multi-pronged, long-term strategies rather than individual one-time initiatives.
17. Indigenous understanding of mental wellness – Base policies and programs on Indigenous concepts of mental wellness.
18. Full inclusion – Ensure Indigenous Peoples are full participants at policy and decision-making tables.
19. Sustainable, flexible, long-term efforts – Provide flexible and innovative funding over a number of years to enable interventions to build momentum and demonstrate long-term outcomes.
20. Evaluation – Embed funding, training and tools to enable interveners to measure outcomes and assess impacts of their work.

Research

21. Cultural competence and research ethics – Develop ways to increase cultural competence and the practice of Indigenous research ethics among researchers.
22. Equally value different types of knowledge – Consider traditional knowledge, local knowledge, lived experience, practice-based knowledge and academic knowledge as equally valuable and useful in different contexts.
23. Develop appropriate measures of effectiveness – Build agreement on the indicators of success and create tools that assist communities and organizations to measure outcomes and impacts of interventions.
24. Evidence-base – Continue to increase knowledge through research and evaluation and apply the best evidence available that is also appropriate to needs.

Symposium participants also provided their longer-term visions and immediate suggestions for follow-up to the meeting. Concerning planning for future conferences and gatherings, almost all participants indicated that the content of this Symposium’s presentations had met their expectations, and they had learned about new initiatives and projects related to mental wellness in circumpolar regions. Across all age groups, there was strong appreciation for the focus on youth and the contributions they made to the presentations and discussion. However, some participants would like to see a more broadly inclusive approach to future meetings – talking circles and/or breakout sessions and roundtable discussions. Other suggestions for future events included: more time for discussion; more cultural experts and Elders; more Indigenous organization representatives leading/facilitating discussions; and even more time and support for Indigenous youth perspectives.

Participants also provided some specific suggestions for follow-up to the meeting:

• urge the Arctic Council to make a statement on the issue at the Ministerial meeting in Iqaluit in April 2015 (this has been accomplished through the Iqaluit Declaration 2015);
• request that the United States Arctic Council chairmanship continue to engage youth in this issue, and also have a permanent branch of the Arctic Council supporting youth representation in all decision-making;
• establish an Indigenous working group with members from across the circumpolar region to support/facilitate ongoing knowledge sharing on Indigenous approaches to mental wellness;
• launch a website where Symposium participants and others can access information and have follow-up conversations with presenters;
• create a virtual/online community to support program development and implementation;
• develop community toolkits for evaluation (indicators, outcomes, templates and instruction guides); and
• hold international meetings on mental wellness every one or two years.

Mental wellness and resilience will continue to be a priority under the US Chairmanship of the Arctic Council 2015‑17, and a project is being developed to build on a need identified at the Symposium for better tools and support for the comprehensive evaluation of mental wellness interventions.

Meetings like the Symposium provide the opportunity for dialogue among groups that do not normally interact with each other, and remain important means of sharing hope, sharing knowledge and moving forward.

Introduction

On March 25-27, 2015, over 100 youth, researchers, representatives from Arctic Council Member States and Permanent Participants, Indigenous organizations and circumpolar communities met in Iqaluit, Nunavut to discuss mental wellness, resilience and suicide prevention. The Mental Wellness Symposium was part of a two-year Arctic Council project and Canadian Chairmanship initiative to assess the evidence for promoting mental wellness and resilience in addressing suicide in circumpolar communities. The meeting was co-hosted by the Government of Canada, the Government of Nunavut and Inuit Circumpolar Council, in partnership with Norway, Kingdom of Denmark (Greenland), Russian Federation and United States.

That suicide prevention and mental wellness promotion is a critical and heart-wrenching issue for circumpolar Indigenous Peoples was a given at the Symposium. Participants were there to exchange knowledge based on first-hand experiences, research, Indigenous ways of knowing and expertise gained from practice in the field. They were there “sharing hope” for the future.

Background and Context

“The Arctic Council initiative on mental wellness is innovative because the research took place in the North, for Northerners. By working together we can achieve significant steps forward.”

The meeting in Iqaluit built on several international circumpolar gatherings, declarations and reports that began in 2003 and will continue into the future. The Arctic Council continued to drive work forward in 2013 with the Kiruna Declaration, setting out the priorities for the Canadian Chairmanship (2013‑15). Below is a synopsis of Arctic Council Circumpolar Mental Wellness events that helped to raise the profile of the issue and contribute to solutions to this fundamental Arctic human development issue.

Circumpolar Mental Wellness Events

• March 2003 – Initial Gathering on Suicide Prevention
• November 2009 – Hope and Resilience: Suicide Prevention in the Arctic Conference in Nuuk, Greenland
• March 2015 – Arctic Council Circumpolar Mental Wellness Symposium in Iqaluit, Canada

For more details and a complete list of reports, projects and chairmanships, please refer to Appendix B.

Overview of the Circumpolar Mental Wellness Symposium

Symposium participants came from Canada, Finland, Kingdom of Denmark (Greenland), Norway and United States. About 25 youth attended the gathering, including 17 Canadian Arctic students and young leaders who were recipients of travel awards by the Canadian Institutes for Health Research. A strong presence of youth was set as a priority during planning for the meeting.

“Suicide must be talked about. It is not about the numbers or the statistics, but the people we have lost, and those who are left behind to carry on. The question that continues to haunt us is why? We need to share and discuss what works and how we can ensure that our lives remain grounded and supported for the future of our peoples in the Circumpolar world.”

The meeting took place over 2½ days and consisted mainly of individual and panel presentations and open discussion (see the full program in Appendix D). Elisapi Aningmiuq, Program Coordinator at Tukisigiarvik Centre in Iqaluit, and Michel Perron, Vice-President, Canadian Institutes of Health Research, acted as moderators. Lena Evic, Jean Kigutikarjuk and Ceporah Kilabuk of Iqaluit, Nunavut provided a traditional welcome and prayer while lighting a qulliq (Inuit soapstone lamp).

The Hon. Leona Aglukkaq, Chair of the Arctic Council; Hon. Paul Okalik, Minister of Health, Government of Nunavut; and Mr. Duane Smith, President, Inuit Circumpolar Council – Canada, provided opening remarks. The following panel discussions were held: Research Projects Wrap-up; Regional Perspectives on Mental Wellness Interventions in Various Settings; Making Policy Relevant to the Needs and Priorities of Communities; and Youth Perspectives on Communities’ Engagement, Cultural Values, and Importance of Self-Awareness. Several video and in-person testimonials were interspersed throughout the Symposium, including those by Jordin Tootoo, Jon Henrik, and Aviaq Johnston.

On the final day of the Symposium, participants discussed main themes and ideas for moving forward in the promotion of mental wellness and prevention of suicide. In addition to group discussion, many of those attending also provided written comments in a feedback survey, which are also captured in this report.

“… I lost my brother to suicide. In my 20s I dealt with my own addictions, my loving sister helped me…. My story is a reflection of the many challenges we face in our territory. A day will come when people have more hope from the beginning and receive help when they need it.”

Woven through the Symposium was the importance of approaching mental wellness from an Indigenous point of view, which is different from that of the Western dominant society, as presented by Gert Mulvad, Greenland Centre for Health Research, and member of the ICC Circumpolar Health Committee.

Cultural values

Source: Gert Mulvad, Regional Perspectives on Mental Wellness Interventions in Various Settings, Circumpolar Mental Wellness Symposium, Mar 26, 2015

Rather than presenting speaker-by-speaker proceedings of the Symposium, the remainder of the report is organized by major topics and themes, and includes findings and conclusions from the Arctic Council’s promising practices research as well as the knowledge sharing Symposium. It reflects perspectives of the Arctic States and Arctic Council Permanent Participants, researchers, policy makers, practitioners, youth and community leaders. It summarizes key principles and lessons learned for moving forward.

Mental Wellness and Resilience in Circumpolar Communities

Laurence Kirmayer of the Division of Social and Transcultural Psychiatry, McGill University, provided an overview of mental wellness in the North at the Symposium. He observed that Indigenous Peoples have a distinct history, identity, culture and values. They also share experiences of encroachment on their territories and the imposition of bureaucratic structures and a loss of control, which especially impacts young people. Forced change and suppression of culture are very destructive. For Indigenous Peoples, strategies to strengthen resilience include four main themes: 1) connection to the land and a sense of place; 2) recuperation of tradition and language; 3) storytelling; and 4) political activism as a source of individual and collective agency.

The idea of “wellbeing” is a broader concept than mental health issues, and different from mental health problems. However, we cannot ignore mental health conditions and illnesses, and therefore need a multi-pronged approach. For Indigenous Peoples, wellbeing depends on connections to others, the land in which they live, and connection to the spiritual world, which are often overlooked in Western approaches to mental wellness.

“Mental health literature has a huge emphasis on individual factors, which are important, but not the whole picture for Indigenous Peoples.”

Kirmayer made reference to the “alarmingly high rates of suicide” among circumpolar youth in particular, and reminded us that for every person who dies, many others are in distress.

Figure 1: Mean age-standardized suicide rate in the 8 Arctic States and their northern regions for the decade 2000‑2009

Fig. 1. Mean age-standardized suicide rate in the 8 Arctic States and their northern regions for the decade 2000‑2009. Note: Direct age-standardization to the European Standard Population. Sources: National statistical agencies including the National Center of Health Statistics (USA), Statistics Canada, Statistics Iceland, Statistics Norway, Socialstyrelsen (Sweden), Statistics Finland and Rosstat (Russia); and international databases (NOMESCO, Eurostat).

Young, T. Kue; Revich, Boris; Soininen, Leena. Suicide in circumpolar regions: an introduction and overview. International Journal of Circumpolar Health, [S.l.], Mar. 2015. ISSN 1797‑237X.

Christina Larsen, National Institute of Public Health, University of Southern Denmark, observed that in Greenland, from one generation to another, men begin dying by suicide at younger and younger ages. There also is regional variation in rates, with lower rates in the capital city, and higher ones in remote regions.

Figure 2: Rate of suicide in Nunavut and Canada overall from 1972 to 2014

Source: Hicks, Jack, Statistical data on death by suicide by Nunavut Inuit, 1920 to 2014, Nunavut Tunngavik Inc. 2015.

Eduardo Chachamovich, team leader for the Resilience and Suicide Prevention (RASP) study, also presented some research results that shed light on the issue of suicide in circumpolar regions. While suicide rates vary from region to region, they all are unacceptably high, and an indication of a failure in other systems. Suicide ideation (thoughts) and attempts also are high. The Inuit Health Survey, a comprehensive survey conducted in Canadian Inuit communities in 2007‑08 indicated that almost half (48.5%) of respondents had thought seriously about suicide sometime in their lives, and about one-third (35.9%) had attempted suicide.

A research study in Nunavut, Canada, Learning from Lives That Have Been Lived, used a psychological autopsy technique to examine the factors contributing to all 120 suicide deaths among Inuit in the territory from 2003 to 2006, compared to a comparison group. The average age of those dying by suicide in Nunavut was 24.6 years. They also were more likely to be: single, unemployed, involved in legal difficulties, and less educated than the control group. Childhood physical or sexual abuse also was more common as were mental health problems and alcohol dependence (Chachamovich & Tomlinson, 2013). These results indicate that there are “windows of opportunity” for interventions to prevent suicide.

Jordin Tootoo Testimonial
National Hockey League Player for the New Jersey Devils

“August 28, 2002 – that day changed my life forever. My brother Terrence took his own life.” Jordin Tootoo is from Rankin Inlet, Nunavut and is the first Inuk to play in the NHL. In the video, he talks about his grief over his brother’s death, the rough years that followed, and how he turned his life around four years ago. He wants youth to know that people in the communities are battling similar problems, and has started the Team Tootoo Fund to raise awareness for suicide prevention and youth at risk. Jordin keeps in his heart the words Terrence left with him in a note: “Go all the way – take care of the family – you are the man.”

Research on Promising Practices in Mental Wellness and Resilience

In 2013, the Arctic Council endorsed a research project to address mental wellness in circumpolar communities. The formal title of the project was The Evidence-Base for Promoting Mental Wellness and Resilience to Address Suicide in Circumpolar Communities and it had a particular focus on children and youth. This initiative was expected to:

• identify promising interventions that reflect Indigenous practices, values, and reality, and could be applied to other communities;
• examine the contextual factors, including financial and human resources, that contribute to their impact;
• enhance awareness across Arctic Council member states and communities of the approaches being used to promote mental health and prevent suicide; and
• engage communities with increased awareness of what works.

The Canadian Institutes of Health Research provided funding through a call for proposals, and two international research teams were the successful recipients. Eduardo Chachamovich of Douglas Mental Health University Institute, Montreal, Quebec, led the Resilience and Suicide Prevention (RASP) project team, which included Inuit, Inuvialuit and Alaskan experts, as well as Indigenous Principal Applicants. Its research focused on interventions in Alaska in the US, and Nunavik and Inuvialuit Settlement Region, Northwest Territories in Canada. Susan Chatwood of the Institute for Circumpolar Health Research in Yellowknife, Northwest Territories, headed the Mental Well-Being and Suicide Prevention in Circumpolar Communities: Developing an Evidence-Base and Identifying Promising Practices (MWBSP) team, involving researchers in Canada, Kingdom of Denmark (Greenland) and Norway, and Northern and Indigenous organizations. This research focused on interventions in Northwest Territories in Canada and in Greenland. Findings from the research were summarized in the report Sharing Hope: Circumpolar Perspectives on Promising Practices for Promoting Mental Wellness and Resilience (Sustainable Development Working Group, 2015) and a special issue of the International Journal of Circumpolar Health on Suicide and Resilience in Circumpolar Populations.

“One of the main findings, and one that is well known to on-the-ground practitioners, is that suicide prevention requires culturally-grounded solutions that are community-based and community-driven, as well as strong collaborative partnerships between researchers and Indigenous Peoples.”

Case Studies

One of the tasks of the researchers was to identify promising practices in mental wellness and resilience through case studies, which were based on the best available evidence gleaned from published and unpublished literature. Six case studies were identified:

1. Makimautiksat Youth Wellness and Empowerment Camp, Nunavut, Canada (day camp intervention) – an evidence-based and culturally relevant summer camp with an on-the-land component for 9-12 year old Inuit youth to foster wellness, positive Inuit identity, community building and skills development.
2. Teck John Baker Youth Leaders Program, Northwest Arctic Borough School District, Alaska, US (school intervention) – trains and supports Youth Leaders to take responsibility for a positive school climate, talk with peers who show signs of depression or suicidal thoughts and intervene when students show negative behaviours.
3. Aullak, sangilivallianginnatuk (Going Off, Going Strong), Nunatsiavut, Labrador, Canada (land-based harvesting intervention) – a land-based youth mental health outreach program to help build resiliency among youth with multiple risk factors and limited access to going on the land and learning land-based skills. 
4. Sámi Youth Team Clinic (only in Norwegian), Finnmark County, Norway (clinical intervention) – a four-member, culturally competent team provides easy access to treatment for suicidal behaviour and substance abuse, including the recent addition of text messaging for youth to contact the team for immediate support.
5. Tlicho Community Action Research Team, Northwest Territories, Canada (community action research intervention) – focuses on turning research into action while integrating Tlicho values and beliefs. The team organizes an annual youth conference and “I am Beautiful Because” workshop to enhance self-esteem and provide youth with tools and resources to succeed.
6. National Strategy for Suicide Prevention, Greenland (policy intervention) – adopted in 2004 and continuing until at least 2019, this national strategy represented a new multi-sectoral and partnership-based approach to suicide prevention that also provides a platform for public discussion on the issue and the sharing of ideas about preventing suicide.

Each of these promising interventions is further described in Appendix C. More information can be found in the Sharing Hope report, or from the sponsoring organizations.

The case studies identified the following seven “common ingredients” in these successful interventions.

Literature Review and Community Engagement

The research teams also carried out an extensive systematic literature review of peer-reviewed academic papers, government reports, documents published by local Indigenous organizations and unpublished reports by researchers and professionals in the field. They found that:

“Scientific literature on suicide prevention programs for circumpolar communities is sparse with the majority of data on prevention interventions found in non-academic sources.”

After reviewing about 400 information sources, the researchers identified 6 interventions that had been formally evaluated and published in peer-reviewed literature (these are listed in Appendix C). One conclusion is that intervention programs require more rigorous evaluation to determine if they are effective and sustainable and backed by evidence. However, this is not always easy in circumpolar communities that often are small and geographically dispersed, providing limited sample sizes.

A major theme in the literature is that community-based programs achieve results, and are recognised as effective approaches for promoting mental wellness and resilience. From the evaluated programs identified, the research team identified the following promising practices.

Community engagement was a major component of the research projects. To determine if what works in one Arctic region could be adapted for others, the researchers invited four Indigenous communities to provide their feedback on the promising practice models identified in the literature review. The team engaged a total of 141 Indigenous youth, adults and Elders in talking circles, focus groups and interviews.

While community members rated all of the practices very positively (8.72 on a 10‑point scale), they had different opinions on what interventions were most likely to be effective in their community, reminding us that a “one size fits all” approach to circumpolar mental wellness promotion will not be effective.

The four highest-rated interventions, in order, are:

1. cultural and land-based programs;
2. programs that focus on youth and Elders;
3. teaching life skills, coping methods and ways of dealing with stress; and
4. healing and grieving groups and circles.

The list below provides a summary of results of the community consultations.

The researchers concluded from the community consultations that interventions need to be made at the individual and the community level, adapted to specific communities and needs, build on community systems already in place, and be sustainable (they need to be in place long enough to show results).

Discussion

Symposium participants posed a number of questions and added several points to the interpretation of research findings. For example, Jim Allen, University of Fairbanks, Alaska, noted three themes in the results: the need for 1) multi-level interventions that are 2) culture-based and 3) sustainable. Pamela Collins, US National Institute of Mental Health, commented on the importance of connectedness for participants – to their communities, to Elders and to each other.

Further discussion by audience members emphasized the importance of:

• re-connecting at-risk individuals to the land for its own sake (the land as healer) as well as the skills/sense of mastery and access to harvested foods that being on the land can provide;
• addressing protective factors in interventions, for example, giving youth social connections, relationships with healthy adults and people who care about them;
• being aware of gender differences as well as the needs of lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals and making sure interventions are inclusive and effective for different groups;
• providing leadership opportunities for youth and enabling them to help others;
• ongoing training and opportunities to share knowledge;
• continuous rigorous evaluation of interventions; and
• looking at what is needed to “scale up” or expand successful interventions to other communities, that is, addressing both commonalities and differences among Indigenous Peoples and regions, and keeping context and local preferences in mind.

Jon Henrik Testimonial (video, only in Swedish)
Saami Reindeer Herder Winner, Sweden “Idol” Contest

As Jon Henrik was unable to attend the Symposium, Jon Petter Stoor, Saami National Competence Centre, Norway, presented the video testimonial. Jon Henrik is first and foremost a Saami traditional reindeer herder. As a young man, he lost a close friend, and fellow herder, to suicide. Jon wrote a song commemorating his friend Daniel, and performed it to a profoundly moved audience at the Swedish Talang Sverige (Swedish “Idol”) contest in 2014, winning the national competition. In the words of Jon Petter Stoor, Jon Henrik “brought pride and strength to Saami – you don't need to assimilate to reach your dreams.”

Research and Policy Perspectives

Participants in the Circumpolar Mental Wellness Symposium spent some time considering the close connections between research, policy and program development. They concluded that research and evaluation are fundamental to evidence-based programs, as long as different types and sources of knowledge are respected. As the graphic below shows, research follows the setting of an agenda or priority issue and the allocation of resources to that issue, with the knowledge generated to be used to implement and deliver services. Monitoring, evaluating and learning from implementation in turn create new knowledge and more effective interventions.

Figure 3: Generating the evidence for action

Source: Pamela Collins, Generating the Evidence for Action, Circumpolar Mental Wellness Symposium, March 27, 2015 (adapted from Moon et al. PLoS Med 2010)

Research that Creates Knowledge

Throughout the Symposium, panelists and audience members emphasized that research must serve the needs of communities, Indigenous Peoples and populations directly affected by an issue, and involve these groups in all stages of carrying out research and disseminating the knowledge generated.

“As a non-Indigenous scholar, you are aware of your area of knowledge, and aware of letting others take the lead where they have knowledge.”

Both of the research teams involved in the mental wellness and resilience project spoke about the importance of utilizing wide networks to both identify sources of information and analyze results within a cultural context. The teams included Indigenous investigators and partnering organizations. Many health research funders now require this approach. Equally important is making sure new knowledge reaches decision-makers and program providers, which the research projects are addressing through a variety of means, including websites, plain language summaries, conference presentations and journal articles.

“Indigenous Peoples define and understand the circumstances surrounding their lives in terms of multifactorial processes, rather than taking a problem-specific approach.”

Valuing different types of knowledge, for example, traditional knowledge, local knowledge and practice-based knowledge, and applying them to mental wellness interventions, provides the greatest value and impact. The box below describes the types of knowledge discussed at the Symposium. All of these sources of knowledge contribute to our understanding of the issues and help us design effective policies and programs that can make a difference.

Participants emphasized that effective program evaluation also can draw on any of these sources, and that different types of knowledge can be used for different purposes; for example, funders want to see academic research to justify a program, whereas communities will rely most on Indigenous traditional and local knowledge.

Concerning knowledge resulting from more formal evaluation, some discussion took place about appropriate indicators and measures of suicide prevention and mental wellness promotion. Numbers of suicides alone are not an adequate measure, nor are suicide attempts or ideation, when this data is used alone. However, there also is a lack of tools available to specifically assess “wellness.” Norway has identified some broad indicators of mental wellness.

“Indicators [used in Norway] that are of relevance to mental health include: wellbeing in school, reading skills in school, bullying in school, drop out from school, mental disorders seen in primary health care, prescription medication for mental disorders, self-reported health, social support, and a large number of social background factors.”

While Symposium participants were clear that action on what we know now about mental wellness promotion and suicide prevention is enough to implement effective interventions, they also identified these future research priorities to add to our knowledge:

• more rigorous evaluation of interventions, using all types of knowledge (Indigenous traditional, local, lived experience, practice-based and academic) and looking at how well accepted and how meaningful programs are to the communities they serve;
• looking at the long-term impacts of interventions and why some regions have low rates of suicide and others do not;
• community or collective factors in mental wellness (emphasis has been on the individual);
• the effects of childhood and adult trauma; and
• deeper investigation of culturally-based initiatives.

Policy that Enables Change

“It's our job to open the doors so people can choose their pathways to wellbeing.”

The Symposium included a policy-specific panel with four presenters who described different policy approaches as well as key elements for success. All of the presenters emphasized integrated approaches that build on and support local needs and strengths.

Greenland first established a National Strategy for Suicide Prevention [ PDF (537 KB) - external link ] (only in Danish) in 2004, and is now implementing a second one for 2013‑2019. According to Christina Larsen, an advisor to the Greenland Ministry of Health, having a national strategy doesn't necessarily solve the problem of suicide, but it provides clear direction and a systematic approach. The current Strategy focuses on providing the skills for people to take action on suicide prevention, efforts in the education and health systems (integration of the topic in school education), reaching out to the bereaved, and evaluation and research (they have been collecting data since 1993). The Strategy is considered to be effective in part because it respects local priorities and builds on local knowledge and evidence.

In describing the Norwegian approach to mental wellness policy, Solfrid Johansen, Norwegian Institute of Public Health, noted that the Public Health Act assumes that health is a multi-sector responsibility. A national information system provides municipal and county-level data (including both risk and protective factors), and a national health action plan provides overall direction, but municipalities are charged with action on health issues. There is formalized cooperation between schools and the school health service, which works to prevent mental health problems and promote good mental health among children and adolescents, and schools are charged with developing better learning environments. There also is a national information bank of evidence-based interventions for child and adolescent mental health.

“Most of the evidence shows that having a strategy is in and of itself an important part of prevention.”

Alison Crawford, Centre for Addiction and Mental Health, believes that policy is best developed through a process that engages communities, stakeholders and knowledge experts. Knowledge experts are broadly defined and include those with scientific, cultural, clinical, and administrative knowledge. She also spoke about two strategies that hold promise because they include broad engagement, are informed by current evidence, attend to community and cultural needs, and commit to evaluation. The Nunavut Suicide Prevention Strategy [ PDF (622 KB) - external link ] and Action Plan [ PDF (707 KB) - external link ] were developed through community consultation and multi-stakeholder involvement. The Strategy contains eight commitments, which include the government taking a more focused approach; strengthening the continuum of mental health services; better equipping youth to handle life’s challenges; and consistently delivering training. The Action Plan focuses on specific means to implement the strategy. Inuit Tapiriit Kanatami, the national Inuit association, also is creating a national Inuit suicide prevention strategy that will draw on World Health Organization, Quebec and Scottish frameworks, which are seen as “gold standards.”

Lynn Ryan MacKenzie, Government of Nunavut, Mental Health and Addictions, emphasized the key role of communities in identifying and addressing the needs of their citizens, and observed that government policy makers have very little influence until an issue becomes a crisis, as illustrated below.

Figure 4: Who influences outcomes

Source: Lynn Ryan MacKenzie, Making Policy Relevant to the Needs and Priorities of Communities, Circumpolar Mental Wellness Symposium, March 26, 2015 (Adapted from Gottlieb, Sylvester, Eby. Transforming Your Practice: What Matters Most. Fam Pract Manag. 2008;15(1):32-38))

MacKenzie advocates for a policy shift:

• from government-led consultation to citizen-led planning/decision-making;
• from independent, isolated projects to integrated sustainable strategies;
• from a deficits/needs focus to a strengths/assets focus; and
• from service provision to community capacity development.

However, she also cautions that external supports mustn’t replace natural support systems, but rather strengthen them.

Discussion

A common value that emerged in discussion of mental wellness research and policy is the centrality of comprehensive, ecological approaches rather than research that is done in isolation from community needs, and one-off projects or programs not linked in a systematic way.

Throughout the Symposium, participants reiterated the importance of Indigenous leadership in strategies and policies.

“A key principle would seem to be having Indigenous communities involved at the [decision-making] tables, not just in consultation, but as co-leaders.”

Natan Obed, Nunavut Tunngavik Inc. observed, however, that currently there are imbalances in the power to make policy, that is, not everyone has access to that process. He reminded us not to limit ourselves to “what governments think is possible” and to push the boundaries in making change. Other participants reiterated the value in putting as much of the decision-making at the community level as possible. As one youth delegate put it:

“As an Inuk person, I can say that something that does not work is copy-pasting southern programs into our communities, which are culturally different.”

Equally important is ensuring that the full continuum of mental wellness interventions, from primary prevention, through treatment, to aftercare, are in place in communities, and whenever possible, these programs and services are delivered by Indigenous service providers. The Assembly of First Nations and Health Canada recently released a First Nations Mental Wellness Continuum Framework [ PDF (1.53 MB) - external link ] (2015) which includes four key wellness outcomes based on the Four Directions of the Medicine Wheel – hope, belonging, meaning and purpose, as well as a continuum of essential services.

Symposium participants discussed the issue of targeted versus universal programs. There was general agreement that universal programs (one approach for the whole population) do not meet the needs of minority Indigenous Peoples, and that equity-based approaches and Indigenous-specific interventions are more appropriate and effective.

Several Symposium participants reminded us of the negative effects that resource development and environmental degradation can have on traditional lifestyles and access to Indigenous land, urging governments to take a broad multi-sector approach to mental wellness research and policy. Finally, discussion reinforced the need for leadership, decision support, systems management and sustainable funding for research, policies and programs; as well as the importance of Indigenous knowledge-based and practice-based evaluation of strategy roll-outs in communities.

Indigenous Youth and Community Perspectives

“Saami have a saying – grief shared is halved, joy shared is doubled.”

Indigenous youth and many others at the Symposium emphasized the phrase “Nothing about us without us” throughout the meeting, in relation to research, government decision-making and program development. Also, the central importance of youth and community in promoting mental wellness and reducing suicide was a shared value of Symposium participants.

Youth Leadership

While youth participant comments were reflected throughout discussion at the Symposium, youth also had two dedicated forums: an evening gathering on day one and a youth panel on the third day of the event.

An evening Youth Forum was organized by a small committee of Iqaluit-based youth, supported by Nunavut Tunngavik Inc., (the Inuit land claim organization in Nunavut), the Government of Nunavut and the Institute of Aboriginal Peoples’ Health of the Canadian Institutes for Health Research. The goal was to create a safe space for youth to network and exchange views and insights on topics of interest to them, in order to support their ongoing efforts as youth leaders. The gathering combined small rotating discussion groups on post-secondary education, traditional knowledge, and national and worldwide travel with contemporary music and yoga for a healthy body and healthy mind. Youth performances also were included. As those reporting to the Symposium the next day said, “We don’t have any demands or a manifesto; we wanted to use the time to make connections and be together as youth.”

Members of the panel on day three – Youth Perspectives on Communities’ Engagement, Cultural Values, and Importance of Self-Awareness – talked about their personal journeys through sometimes tough times to their experiences in leadership and activism in circumpolar Indigenous communities and organizations. They very much were able to put a “human face” on the strengths and challenges facing youth in the Arctic.

Anguti (Thomas) Johnston, President of the National Inuit Youth Council (NIYC) in Canada, began his remarks by saying he wanted to talk personally to help the audience of researchers, policy makers and members of Indigenous and community organizations to better understand suicide. He admitted that as an Inuk man, he can be irrational when upset, doesn't easily seek help for problems he is facing, and gets embarrassed about sharing emotions. His family wasn’t close and he didn’t learn many traditional skills as a youth, which he is shy about now. At the age of 19, he has two daughters but lacks education and “life knowledge.” Anguti has observed that some people do not “fit in” well in their communities, because of skin colour, sexual orientation, etc., and he sees this as a problem. He has lost friends and family to suicide, has had dark times himself, but still sees hope and strength around him. He ended his presentation by asking that we support Inuit and other Indigenous youth as they work to find solutions to the tragedy of suicide.

“There is a saying that good work means hard work. The Inuit youth of Canada are willing to put in that work, we just need a bit of help.”

Aili Liimakka Laue is a Board member with the National Inuit Youth Council – Greenland. She considers herself lucky to have grown up in the North. She comes from a mixed-culture family, with a father who had a mental illness, and she struggled to find her own identity as a person and an Inuk. Travelling helped her with this because when you travel, you have to explain who you are and who Inuit are to others. She eventually became a student activist in Kingdom of Denmark, fighting for her Indigenous rights along with others, but she needed to return home to Greenland because she had children and needed help from her family. For Aili, mental wellness is about being a part of a community and who you are in a family. She works at the international level with the Inuit Circumpolar Council to bring about change. Issues of suicide and sexual abuse are topics at each international summit she attends, and a personal victory for her was getting endorsement for a statement on suicide at an Indigenous rights conference in 2014. She feels she has found her place in the world now, even though it is sometimes scary to talk in front of large international audiences.

Kluane Ademek is from the Kluane First Nation, Yukon, Canada, and currently is the director of government relations at Northwestel and co-founder of the group Our Voices – Yukon First Nation Emerging Leaders l. She spoke about her work in organizing the Our Voices: Northern Indigenous Gathering. The planning group came together after many members had losses to suicide in Yukon and wanted to build a support network. This resulted in a week-long gathering of Yukon Indigenous Peoples, on the land, in the summer of 2014. Kluane and others found the week to be an incredible learning experience but it also brought up lots of feelings for participants. Many youth do not have ongoing support in their communities. For her, the gathering was about “culture and feeling connected and knowing who you are” and the importance of art and music and culture.

The group met again after the summer gathering for strategic visioning, and are planning an event to honour youth. Kluane ended her presentation by naming three things she wants for Indigenous communities and youth: 1) safety, support and security in communities – creating safe spaces and training in mental health first aid; 2) put language and culture at the centre, and support young people “to be the best they can be;” and 3) provide training and tools for youth to do their own research and evaluation.

John Stuart Jr. is Youth Wellness Coordinator for the Inuvialuit Regional Corporation in Northwest Territories, Canada. He was also an Indigenous co-applicant for one of the mental wellness research projects. John opened by saying he was proud to be using some Inuvialuktun, which he is trying hard to learn. He grew up dealing with substance abuse and family problems, and his mother was a residential school survivor with mental health problems. He struggled with addictions as a youth – hunting and fishing on the land helped him, as did sports. He became an athlete, competing in the Canada Games and Northern Games, which helped keep his mind off his problems. At the age of 15, he had a son, which after a few difficult years, changed his life for the better. He wanted to live a better life for his son. To get on the right track, he started volunteering and coached sports and worked at a youth centre. Youth began coming to him with problems, and he studied on his own to make sure he was saying the right things to them. For John, self-esteem is healing, and by that he means “knowing who we are, where we are from.”

Symposium participants were appreciative of the youth sharing their personal stories, agreeing that culture and time on the land is “so important, identity is so important.” Several noted how important it is for youth to have safe places for sharing and getting support while growing up in their communities, but this can be hard to find in small communities that are under-resourced and where confidentiality can be a problem. Youth also can be afraid to speak out, but should not allow themselves to be silenced. Particular attention needs to be paid to young men, because they are often reluctant to seek help, but we need also to be conscious that Aboriginal girls are born with “two strikes against them” in modern society.

Community Solutions

Circumpolar community perspectives were provided by both panel members and Symposium participants throughout the meeting. For example, in his presentation, Per Jonas Partapuoli, Saami Youth Association, described both the joys and the hardships of the reindeer herding life in remote communities in Sweden; the dark side is the estimated one in three herders aged 18 to 29 who have considered suicide. As Partapuoli says:

“I feel incredibly sick living with the feeling of wondering who will die next.”

Herding is being compromised by encroachment onto the Saami traditional lands for mining and wind farm development. He sees this as a “double punishment” – Saami land is being taken but there is little help with the consequences for the Saami people. Saami men in particular have a hard time talking about how they feel, and some see no other alternative than suicide. Often, those who do seek help have to educate the service providers about Saami culture and values. After the death of a community member, they started a community choir to provide support to each other and to celebrate life.

Saami youth have begun to recognize the unique needs of the lesbian, gay, bi-sexual, transsexual and queer (LGBTQ) community members and started the LGBTQ Democracy Project, helping to make Saami a more open society. They have published a book and held an art exhibition, and recently organized the first Sami Pride event.

Minnie Grey, Nunavik Regional Board of Health and Social Services, described structures and programs for Inuit mental wellness in Nunavik, Quebec, Canada. Through an Inuit-led regional health and social services board, they deliver services in three tiers involving primary care and mental health teams. They work closely with specialists in Montreal, including child psychiatry services. A regional mental health steering committee oversees all programs, and there is a community-based working group to advise on promoting mental health and preventing mental disorders. Community liaison workers coordinate efforts with community health committees. Grey’s primary message was:

“[We need to] take charge of how the services are given, and made culturally relevant – how they can be better integrated into our way of life.”

In a presentation on behalf of the Arctic Athabaskan Council, and one of its constituents, the Council of Yukon First Nations, Bob van Dijken noted that none of the Yukon territorial government mental health programming is First Nations-specific; residents must have a medical diagnosis to receive mental health services and there are long waiting lists for counselling. Many First Nations continue to suffer from Indian Residential School Trauma and its intergenerational effects, including drug and alcohol abuse, oppression, assimilation, loss of identity and culture, etc. Similar to other Indigenous Peoples, on the land programs involving youth and Elders have been vital for Yukon First Nations. Due to a voluntary halt to chinook salmon harvesting to rebuild the fish stocks (which could take another 14 years), communities have resorted to bringing in frozen salmon so that this generation of youth can at least in part continue to process the salmon. A dwindling caribou herd also threatens cultural continuity in harvesting as well.

A repeated theme at the Symposium was frustration with funding silos (funds for very specific programs), and lack of sustained funding for promising interventions (enough time to prove their worth) and known successful programs. One participant, Bernadette Dean, Kivalliq Inuit Association, Rankin Inlet, Nunavut, described a highly successful land-based program showing clear results but which no longer has funding. On the other hand, in the Northwest Territories, Canada, the territorial government and federal government provide open-ended funding to local communities to address mental wellness issues. Regional coordinators are available to help communities develop their plans. Unspent funds in one year can be transferred to the next year. This flexible approach enables communities to develop their own priorities and work together to achieve better mental wellness. Symposium participants also mentioned the Public Health Agency of Canada’s Innovation Strategy fund as a multi-year source of funding with a strong evaluation component.

Ethel Blake, Gwich’in Council International, described on-the-land programs in Gwich’in communities. They may not have written evaluations but assess “success” in what they observe among participants.

“How do we know our on-the-land programs are working? We can see it in the eyes of participants. They are clean from the inside out.”

Gwich’in communities also take new school teachers onto the land, so they understand this aspect of Gwich’in culture. Her community of Fort MacPherson celebrates life though music and dance one weekend in the summer and holds a fishing derby in the fall. They also run a kids’ trapping program, which builds relationships among Elders and youth, teaches skills and builds self-esteem. Blake supports the idea of regular family celebrations, celebrating even those who have died, as well as government support for the natural “helping” that is a part of the Gwich’in culture.

Concerning other Indigenous approaches, the research report, Sharing Hope: Circumpolar Perspectives on Promising Practices for Promoting Mental Wellness and Resilience contains a section on the roles, perspectives and priorities of the six Indigenous Permanent Participant organizations of the Arctic Council. Excerpts are included below.

Discussion

In discussing Indigenous youth and community perspectives, Symposium participants reinforced the importance of community direction and involvement in solutions. As one participant put it:

“Indigenous knowledge holders have their own processes and practices in use – we need to release this capacity in communities, not “build” it.”

However, the structures that help to make this happen are not universal – Evelyn Stoor, Inuvialuit Regional Corporation in Northwest Territories, Canada, commented that they used to have a regional health board that worked in partnership with health-related projects but the board was disbanded. However, in some communities they have Elders groups that work with community justice committees to provide counselling and support services. This comment echoed others – that much of the responsibility for mental wellness should reside within the community, but as Indigenous youth have said, this requires support.

Participants also raised concerns about the lack of continuity in mental health services, clinicians who are not a part of the community, and gaps in community capacity to address issues. Lisa Wexler, Department of Health Promotion and Policy, University of Massachusetts Amherst, and a community-engaged researcher working in rural Alaska, noted that if counselling services are not provided in a culturally competent way, community members will not use them. Clinicians need to understand the community and family context of their clients and cultural ways of expressing distress and caring. Work is being done in Alaska to bridge the gap between clinical providers, community workers and communities.

In further discussing youth and community perspectives, audience members also expressed concerns about the dangers of stereotyping certain populations in efforts to de-normalize suicide, and about the language used to talk about the issue (e.g., never using the word “successful” suicide).

Some other points raised in relation to Indigenous youth and communities included: the value of the language component in on-the-land programs, being able to allocate funds according to community priorities, and forming partnerships among organizations.

Symposium participants called for the following in developing successful Indigenous community mental wellness interventions:

• ensuring that the full continuum of mental health and mental illness services are available to the community;
• addressing gaps in services and short-term funding, and providing flexible funding;
• providing training to community service providers, families and community members; and
• hiring and developing local service providers (this can take several years).

Aviaq Johnston Testimonial
Winner of Canada’s Governor General’s Award for History

Aviaq Johnston is a young Inuk writer from Iqaluit, Nunavut who won the 2014 Governor General’s Award for her short story “Tarnikuluk.” Tarnikuluk is an Inuktitut word meaning "little soul." As Aviaq says “My story speaks about [assimilation, residential schools, relocations –] these intergenerational effects as experienced by the spirit of a young Inuk woman who has recently died by suicide. On this journey to the afterlife, she is guided by Tulugak, a raven in Inuit mythology.” Aviaq had lost a number of friends to suicide, and wanted to create a dialogue for youth on the topic.

Key Principles and Lessons

In summarizing results of the first two days of the Symposium, Kimberly Elmslie, Public Health Agency of Canada, reminded the audience that the commonalities in community approaches and promising practices need to be put into context, and we are “collectively worried about sustainability” because many of the models we use now are short-term solutions since we do not always have the resources for the long term. We need to look at changing systems so we can improve the way we are working together. We believe in integration but do not always know how to achieve that through our collective passion and insight. We need leadership at all levels, and the courage that all Indigenous Peoples show every time they stand up and talk about suicide.

The following key principles and lessons are drawn from the mental wellness and resilience research projects and discussion and dialogue at the knowledge sharing Symposium as a whole.

Systems

1. Work within an equity model – Target strategies, funding, policies, programs and services to the specific needs and realities of Indigenous Peoples with the aim of creating equity with non-Indigenous populations.
2. Continuum of services – Ensure that communities have access to the full range of programs and services for the promotion of mental wellness and the treatment of mental illnesses.
3. Address social determinants of health – Include the multiple factors affecting mental wellness, such as economic conditions, access to education, poverty, trauma, cultural dislocation, etc. in solutions.
4. Integration – Deliver mental wellness promotion and suicide prevention within existing structures, programs and services whenever possible.
5. Collaboration – Develop knowledge and skills that support collaboration, and expect sectors, disciplines, governments and Indigenous organizations to work effectively together.

Interventions

6. Land-based and other culture-specific programs – Fund interventions that foster cultural continuity and pride, land-based skills, increased access to harvested food, inter-generational relationships, and re-engagement with the community.
7. Focus on children and youth – Integrate mental wellness promoting content and activities for children and youth throughout education, recreation, health, family services and community programs.
8. Indigenous training and program delivery – Whenever possible, train and support local Indigenous people to deliver mental wellness services and programs.
9. Strengths-based approaches – Create interventions that promote responsibility, control over one’s life and the skills to manage challenges.
10. Adapt interventions to specific contexts – Ensure that promising practices are appropriate to geographic, cultural, and community contexts.

Community Capacity

11. Traditional knowledge – Develop ways to preserve and use traditional knowledge, healing practices and Elder teachings related to mental wellness and resilience.
12. Training – Deliver training for service providers, community leaders, families and individuals in promoting mental wellness and reducing suicide.
13. Intervention tools for people at risk – Develop knowledge and tools to strengthen interventions among at-risk populations.
14. Opportunities to share knowledge – Continue to create face-to-face as well as virtual forums to share knowledge and insights.
15. Youth leadership – Provide practical support, capacity development and leadership training to young leaders and youth organizations.

Policy

16. Broad strategies rather than individual policies and programs – Create multi-pronged, long-term strategies rather than individual one-time initiatives.
17. Indigenous understanding of mental wellness – Base policies and programs on Indigenous concepts of mental wellness.
18. Full inclusion – Ensure Indigenous Peoples are full participants at policy and decision-making tables.
19. Sustainable, flexible, long-term efforts – Provide flexible and innovative funding over a number of years to enable interventions to build momentum and demonstrate long-term outcomes.
20. Evaluation – Embed funding, training and tools to enable interveners to measure outcomes and assess impacts of their work.

Research

21. Cultural competence and research ethics – Develop ways to increase cultural competence and the practice of Indigenous research ethics among researchers.
22. Equally value different types of knowledge – Consider traditional knowledge, local knowledge, lived experience, practice-based knowledge and academic knowledge as equally valuable and useful in different contexts.
23. Develop appropriate measures of effectiveness – Build agreement on the indicators of success and create tools that assist communities and organizations to measure outcomes and impacts of interventions.
24. Evidence-base – Continue to increase knowledge through research and evaluation and apply the best evidence available that also is appropriate to needs.

The Way Forward

In discussing “the way forward” from this Symposium, participants emphasized the critical need for ongoing leadership to set objectives and coordinate efforts. However, they also acknowledged that there are no “easy fixes.”

“This is a journey that we are on – a marathon, not a sprint. The next steps require us to build on what we know and move forward… We want to stay on the leading edge of science but also follow what our communities are teaching us.”

On the last day of the Symposium, Pamela Collins, US National Institute of Mental Health, outlined plans for a project under the 2015‑17 US Chairmanship of the Arctic Council that will build on a need identified at the Symposium for better tools and support for the comprehensive evaluation of mental wellness interventions. While it is still under development, the “rising sun” (Reducing the Incidence of Suicide in Indigenous Groups – Strengthens United through Networks) project aims to use a consensus building process to develop common indicators and measures for evaluating suicide prevention efforts in the Arctic. Health officials in the Arctic Council member states, Permanent Participants, community groups, and mental wellness practitioners will work together to assess key measurement indicators and develop toolkits for practitioners and communities. Symposium participants were generally in agreement with this approach, emphasizing the importance of developing measures that meet the needs of a wide range of knowledge users by “getting the right people in the room,” including youth.

In an open discussion forum and through 37 feedback forms provided at the end of the Symposium (representing about 40% of remaining participants – a very high response rate), participants highlighted the follow-up actions and next steps they would like to see to carry forward the momentum of the promising practices research and Symposium.

Youth called for funding for community-based programs across the circumpolar region, as well as a document or follow-up action plan on how knowledge from the research projects and Symposium will be implemented. They also suggested follow-up meetings on themes such as impacts of resource extraction and climate change on mental wellness.

Similar to the youth participants, older age groups also want continuity in research and knowledge sharing – that is, a sustained research agenda and communication on how research results are disseminated. There was a strong call for placing traditional knowledge on par with academic research and looking at ways to protect and prioritize Indigenous values, cultures and traditions.

Concerning planning for future conferences and gatherings, almost all participants indicated that the content of this Symposium’s presentations had met their expectations, and they had learned about new initiatives and projects related to mental wellness in circumpolar regions. Across all age groups, there was strong appreciation for the focus on youth and the contributions they made to the presentations and discussion. However, some participants would like to see a more broadly inclusive approach to future meetings – talking circles and/or breakout sessions and roundtable discussions. Other suggestions for future events included: more time for discussion; more cultural experts and Elders; more Indigenous organization representatives leading/facilitating discussions; and even more time and support for Indigenous youth perspectives.

Participants also provided some specific suggestions for follow-up to the meeting:

• urge the Arctic Council to make a statement on the issue at the Ministerial meeting in Iqaluit in April 2015 (this has been accomplished through the Iqaluit Declaration 2015);
• request that the United States Arctic Council chairmanship continue to engage youth in this issue, and also have a permanent branch of the Arctic Council supporting youth representation in all decision-making;
• establish an Indigenous working group with members from across the circumpolar region to support/facilitate ongoing knowledge sharing on Indigenous approaches to mental wellness;
• launch a website where Symposium participants and others can access information and have follow-up conversations with presenters;
• create a virtual/online community to support program development and implementation;
• develop community toolkits for evaluation (indicators, outcomes, templates and instruction guides); and
• hold international meetings on mental wellness every one or two years.

Conclusion

In providing closing remarks for the Symposium, Jutta Wark, Chair, Sustainable Development Working Group (which sponsored the Arctic Council mental wellness and resilience project), commented on the need to be honest about the severity and prevalence of mental health issues in circumpolar areas, and to continue to engage communities and youth as we create solutions. Meetings like the Symposium provide the opportunity for dialogue among groups that do not normally interact with each other: researchers, communities, and policy and decision-makers.

Two youth delegates, Rachel Michael from Iqaluit, Nunavut and Makenzie Zouboules from Yellowknife, Northwest Territories, also provided heartfelt closing remarks, reinforcing that the Symposium was a valuable experience in meeting, talking, and sharing. They were moved to hear of the struggles of the Saami People, and that they “strive to no longer have to bury their friends.” They echoed other participants’ remarks throughout the gathering about needing to take responsibility, each of us, for this issue.

The Circumpolar Mental Wellness Symposium clearly had an impact on those who attended. Participants felt hope and despair, developed new insights and perhaps looked at issues from new viewpoints. The promising practices derived from the research projects provided both new evidence and confirmed existing knowledge. On this strong foundation, we can move forward.

Appendix A – Selected Bibliography

Articles, Declarations and Reports

• Arctic Council. (2015). Improving Economic and Living Conditions for Arctic Communities – US Chairmanship.
• Arctic Council. (2015). Iqaluit Declaration.
• Arctic Council. (2013). Kiruna Declaration.
• Arctic Council. (2011). Nuuk Declaration.
• Assembly of First Nations, & Health Canada. (2015). First Nations Mental Wellness Continuum Framework [ PDF (1.53 MB) - external link ].
• Bjerregaard, P., & Larsen, C. V. L. (2015). Time trend by region of suicides and suicidal thoughts among Greenland Inuit. International Journal of Circumpolar Health, 74, 26053.
• Chachamovich, E., & Tomlinson, M. (2013). Learning from Lives That Have Been Lived: Nunavut Suicide Follow-Back Study 2005‑10. Douglas Mental Health University Institute, McGill University.
• Government of Greenland. (2013). National Strategy for Suicide Prevention 2013‑19 [ PDF (537 KB) - external link ] (only in Danish).
• Government of Nunavut, Nunavut Tunngavik Inc., Embrace Life Council, & Royal Canadian Mounted Police. (2010). Nunavut Suicide Prevention Strategy [ PDF (622 KB) - external link ].
• Government of Nunavut, Nunavut Tunngavik Inc., Embrace Life Council, & Royal Canadian Mounted Police. (2011). Nunavut Suicide Prevention Strategy Action Plan, September 1, 2011 – March 31, 2014 [ PDF (538 KB) - external link ].
• International Journal on Circumpolar Health. (2015). Special Issue on Suicide and Resilience in Circumpolar Populations.
• Johnston, A. (2014). Tarnikuluk. Governor General’s History Awards, 2014.
• Larsen, C. V. L., Pederson, C. P., Berthelsen, S. W., & Chew, C. (2010) Hope and Resilience: Suicide Prevention in the Arctic (report of a conference in Nuuk, Greenland, November 7‑8, 2009).
• Redvers, J., Bjerregaard, P., Eriksen, H., Fanian, S., Healey, G., Hiratsuka, V., …Chatwood, S. (2015). A scoping review of Indigenous suicide prevention in circumpolar regions. International Journal of Circumpolar Health, 74, 27509.
• Sustainable Development Working Group. (2015). Sharing Hope: Circumpolar Perspectives on Promising Practices for Promoting Mental Wellness and Resilience.
• Tootoo, J. (with S. Brunt). (2014). All the Way: My Life on Ice. New York: Viking Press.
• Young, T. K., Revich, B., & Soininen, L. (2015). Suicide in circumpolar regions: An introduction and overview. International Journal of Circumpolar Health, 74, 27349.

Websites and Links

• Aullak, sangilivallianginnatuk (Going Off, Going Strong), Nunatsiavut, Labrador, Canada.
• Circumpolar Mental Wellness Symposium Panel Presentations. Sustainable Development Working Group, Arctic Council.
• Jon Henrik – Daniel’s Jojk (video, only in Swedish). February 18, 2014.
• Jordin Tootoo Speaks to CIHR about Mental Well-Being and Resilience. March 25, 2015.
• Makimautiksat Youth Wellness and Empowerment Camp, Nunavut, Canada.
• Mapping Inuit Mental Health and Wellness. Atlas of Community-Based Monitoring & Traditional Knowledge in a Changing Arctic.
• Media and Social Media Coverage of the Circumpolar Mental Wellness Symposium. Canadian Institutes for Health Research.
• Mental Wellness Project Data. Circumpolar Health Observatory, University of Toronto and Circumpolar Health Research Institute.
• National Strategy for Suicide Prevention 2013‑19 [ PDF (537 KB) - external link ] (only in Danish), Greenland.
• Sámi Psychiatric Youth Team Clinic (only in Norwegian), Finnmark County, Norway.
• Suicide among Indigenous People is Increasing (report of the mental wellness research project workshop, Tromsø, Norway, May 2014). Norwegian Institute of Public Health.
• Teck John Baker Youth Leaders Program, Northwest Arctic Borough School District Alaska, US.
• Tlicho Community Action Research Team.

Appendix B – Chronology of Circumpolar Mental Wellness Events

Appendix C – Promising Practices Case Studies

1. The Makimautiksat Youth Wellness and Empowerment Camp, Nunavut, Canada

The Makimautiksat Youth Wellness and Empowerment Camp was launched in 2011 in five Nunavut communities following a year and a half long consultation with youth, parents, community members and teachers. Developed in partnership with the Qaujigiartiit Health Research Centre in Iqaluit, this evidence-based and culturally relevant summer camp for 9‑12 year old Inuit youth focuses on fostering wellness, positive Inuit identity, community building and skills development. The program can be delivered in English and/or Inuktitut, and each camp costs about $10,000 to run. Participants spend the first seven days in the community and the last two days and nights on the land. Activities include hands-on arts projects, community events or gatherings and group discussions. An Elder or community member visits the camp each day to share a story or knowledge, and the youth also work with community members on land-based activities where they learn about harvesting foods, living on the land and learning from Elders. Results include:

• following the camp, youth felt an increase in self-esteem, stronger peer and community relationships, a greater willingness to talk to someone about a problem, and greater interest in traditional Inuit activities;
• parents reported significant changes in the attitudes and behaviours of their children, including less anger, increased engagement with peers and with parents, and expressing feelings of happiness and joy at home;
• the program was strongly supported by the communities that offered it; and
• in the four years since the program started, none of the participants has died by suicide.

Some program strengths of Makimautiksat Youth Wellness and Empowerment Camp are: the program is designed to meet the needs of young Nunavummiut, and to work with existing community capacities and resources; and is built on a robust set of data and long-standing collaborations. The program supports aspects of Inuit relational society and the importance of family, peer, and community relationships in the achievement of wellness. A major limitation/challenge is a lack of secure, sustainable funding.

2. Teck John Baker Youth Leaders Program, Northwest Arctic Borough School District Alaska, US

The Teck John Baker Youth Leaders Program (TJBYL) was launched in 2008 and focuses on suicide prevention, wellness and school success. The program is designed to empower youth to take personal responsibility for a positive school climate, and to contribute to the wellness of their communities. Young Leaders receive training to be able to talk with peers who show signs of depression or suicidal thoughts, and can intervene when students show negative behaviours. They also organize recreational activities for students and their families. A total of 87 students were active Youth Leaders in 11 rural schools throughout the 2013-2014 school year. Results include:

• no student in the region has died by suicide since 2010;
• being a Youth Leader was found to increase attendance for high school students in grades 9, 10 and 11; and those is grades 8, 9 and 10 significantly increased their grade point averages after participating in the program;
• many Youth Leaders report that the program has helped them to be more positive, act more responsibly and gain the trust of adults;
• teachers and administrators appreciate that Youth Leaders engage with students; and
• 83% of students who had received an intervention from a Youth Leader thought it was helpful, and preferred this peer intervention over those by adults.

Promising approaches include: providing a structure and process for capacity-building and mobilization; and identifying “natural leaders” and providing ongoing support to them through weekly meetings and monthly videoconferences. Some limitations in the program are: youth leaders feel pressure to always display model behaviour and some do not always do so; they lose skills and enthusiasm by late in the year; and school staff who do not understand the Youth Leaders’ role can underutilize them.

3. Aullak, sangilivallianginnatuk (Going Off, Going Strong), Nunatsiavut, Labrador, Canada

Aullak, sangilivallianginnatuk (Going Off, Growing Strong) is a land-based, youth mental health outreach program in Nain, Nunatsiavut, designed to help build resiliency of youth in the face of widespread social, environmental and cultural change. Delivered through the Nain Research Centre, the program matches experienced and trusted harvesters with youth to take them out on the land, in pairs and as a group, to teach them how to hunt, fish, navigate and collect firewood. Other activities include social events, volunteering and building smoke houses and qamutiks (sleds towed behind snowmobiles). In 2012, the pilot program recruited 10 male Inuit youth identified as having multiple risk factors and with limited access to “going off” on the land within their family network. Operating in both English and Inuktitut, the program has been delivered over an 18 month period in a community of approximately 1,200 people. The program costs approximately $150,000 per year to operate. Initial results point to these successes:

• all participants, as well as program staff and caregivers reported positive impacts on the youth’s mental health; and
• there is active participation and few drop outs among high-risk and typically “hard-to-reach” participant youth.

In terms of strengths, the program has successfully developed a unified approach to complex and overlapping community challenges (e.g., suicide prevention, mental health promotion, cultural connections and food security). It has strong grassroots connections and is supported by harvesters and local governmental organizations. The program builds relationships with youth slowly, over time through active outreach. A key limitation is the lack of sustainable, core funding.

4. Sámi Psychiatric Youth Team Clinic, Finnmark County, Norway

In late 1987 and early 1988, 18 Saami youth in and around the community of Karasjok killed themselves. That “year of horror” became a catalyst for the formation of the Sámi Psychiatric Youth Team in 1990 by the Sámi Norwegian Advisory Unit on Mental Health and Substance Abuse (SANKS) (only in Norwegian). The program takes a culturally sensitive approach to treating suicidal behaviour and substance abuse in Indigenous Saami communities. Each four-member team (psychologist, social worker, nurse, and medical doctor) works primarily with adolescents and young adults ages 15 to 30. The program treats between 80‑120 clients per year, in the Saami language and in Norwegian. The program also supports additional training opportunities in the community and provides local suicide education programs. A recent innovation is the use of text messaging for youth to contact the health team for regular and emergency appointments in case of suicide risk. Team members suggest that simply communicating in writing may have a calming effect for patients. The Youth Team Clinic has had dedicated funding since 1990 – currently €370,000 ($525,000 CAD) per year from the Norwegian government. Results include:

• no suicide deaths among the program’s clients in 25 years; and
• youth recommend the service to friends and discuss their use of the clinic openly with peers.

Program strengths include all staff having either Indigenous heredity and/or native Saami language competence themselves, or formal education in Saami culture; and a low threshold for services, that is, easy access and patient decision-making about how and where the intervention takes place. A limitation is that the team is unable to follow-up with the youth after they exit the program.

5. The Tlicho Community Action Research Team

The Tlicho Community Action Research Team (CART) was established in 2009 to promote health and minimize health inequities among children and youth of the Tlicho Nation in the Northwest Territories, Canada. CART focuses on turning research into action. It evaluates community issues and assists with finding solutions through research-based programming and policy development. Guided by the Healing Wind Advisory Committee, a group of Elders and community representatives, CART integrates knowledge of Tlicho values and beliefs in their work by engaging in close community consultation and involvement at all stages of the research and programming processes. CART receives dedicated funding from the Tlicho Government. An annual Youth Conference addresses issues youth want to learn about and that could help them make healthier choices in life. Some 90 youth and 20 facilitators/program coordinators/volunteers participated in the 2013 conference. The “I am Beautiful Because” Self-Esteem Workshop aims to enhance youth self-esteem and give them the tools and resources to know that they are unique in their own way and have much to contribute to the world. Activities include role-playing, worksheets, team-building activities, and reflection exercises. The process cumulated in a fashion show. Results include:

• youth conference – overall, youth showed a broader perspective for their futures and goals for themselves after the conference; and
• self-esteem workshop – after a one-week session, remarkable changes in youth self-confidence and self-esteem were seen among the nearly 40 youth participants.

Program strengths include a community-based team where all staff members are Tlicho citizens; and CART’s knowledge translation model that uses a two-way communication structure based on mutual respect, shared purpose, and bringing the findings back to the Tlicho people.

6. The National Strategy for Suicide Prevention, Greenland

The National Strategy for Suicide Prevention [ PDF (537 KB) - external link ] (only in Danish) in Greenland (NSSPG) was adopted by the Greenland Parliament in the fall of 2004, and has been renewed until 2019. It represented a new approach to suicide prevention based on the guidelines from the World Health Organization and the Ottawa Charter for Health Promotion. The NSSPG’s main objective is to “to make suggestions aimed at reducing the large number of suicides and attempted suicides seen in Greenland every year”. It aims to achieve this by:

• ensuring that people at risk of dying by suicide are identified;
• giving people at risk, and those in known risk groups opportunities to seek advice and receive treatment – particularly young men;
• enhancing the professional competence of relevant professional groups;
• working against the perception of suicide as a way to solve problems encountered in life;
• increasing well-being as well as youth and adult ability to tackle conflicts and challenges;
• strengthening the ability of local communities and voluntary organizations;
• generating research-based knowledge; and
• evaluating individual initiatives and the action plan.

This approach focuses on multi-sectoral collaborations and the collective strength of the multiple organizations and institutes working to reduce deaths by suicide in Greenland. Between 2005 and 2012, the strategy cost 2.5-3.5 million DKK annually ($500,000‑$650,000 CAD). Strengths include national coordination of the issue, sharing of ideas and results across regions, and acting as an important platform for public and political discussions about the problem of suicide in Greenland. Limitations relate to implementing the strategy within the government system and engaging all sectors. Priorities and available resources at the municipal level also can affect the quality of the prevention work.

Appendix D – Symposium Program

Appendix E – Symposium Participant List

Date modified:

2021-12-07