Invited Commentary: Community adaptations to ACCESS Open Minds—Lessons from Eskasoni and Ulukhaktok

Developing a high-quality system of youth mental health services in Canada is of tremendous importance, not only for improving the lives and prognoses for those youth experiencing mental health difficulties and their families who support them (which should be motivation enough!) but also from a broader social perspective. As noted by Malla et al. (2018), there are a great many reasons why youth mental health should be a priority. However, system transformation is an endeavour that necessarily requires the engagement of the general population at large, as well as specific groups with differential access to care for reasons related to culture and context. For example, Indigenous people comprise 4.9% of the total population of Canada and are the fastest growing segment-growing at a rate four times that of the general Canadian population (Statistics Canada, 2016). At the same time, when compared to youth from the general Canadian population, Indigenous youth experience disparity in proximal, intermediate and distal determinants of health (Reading & Wien, 2009). As a consequence, Indigenous youth have high rates of mental health difficulties. At the same time, Indigenous communities often experience limited access to mental health resources and specialist care. Hutt-MacLeod et al. (2019) describe the adaptation and implementation of the ACCESS Open Minds (ACCESS OM) service transformation objectives for youth in the culture and context of Eskasoni First Nation on Unama'ki. Utilizing the Mi'kmaq concept of Two-Eyed Seeing as described by Elder Albert Marshall (2004), Eskasoni Mental Health Services, in partnership with ACCESS OM, developed a local approach aimed at improving local services to local youth experiencing mental health difficulties and their families. Similarly, Etter et al. (2019) show that lay community health workers are central to meeting contextual needs in Ulukhaktok, as is a continued process of community mapping. For Indigenous people, there has been a long history of imposition of external structures and approaches that fail to take into consideration the unique histories, languages, cultures and contexts inherent in our communities. This has resulted in less than adequate care as well as frustration and hesitance in engaging with such systems. And, justifiably so. Indeed, what has always been needed is a system of service that includes objectives such as those of the ACCESS OM Project: early identification, rapid access, appropriate care, continuity of care and youth and family engagement, but which is implemented within the culture and context of the community served in a manner that incorporates the great wisdom inherent in culture-based approaches to wellness. Indeed, these five objectives are what Eskasoni Mental Health Services and ACCESS OM pursued and what community leaders of Ulukhaktok used as a framework for identifying key activities for sustainable change. The results are as follows: In Eskasoni, mental health services where youth are given the choice between mental health services as usual, Mi'kmaq methods of improving well-being, or a combination; and In Ulukhaktok, attunement of the ACCESS OM framework to Inuit paradigms and a potentially sustainable working model for others to consider in the Inuvialuit Settlement Region and Inuit Nunangat. These collaborative examples of the gift of multiple perspectives have the potential to inform the transformation of systems of service in other Indigenous communities. But, there remain a few considerations for further development. Which age demographic to prioritize and the timing of such prioritization depends upon level of analysis. For example, if considering attachment mediated neurodevelopment in the context of adverse childhood experiences (ie, ACEs), ages 0 to 6 years are relevant. Epidemiological ACEs data suggest the window should include ages 0 to 18 years. If considering developmental onset of mental health difficulties, as ACCESS OM does, youth ages 11 to 25 are the focus. Indigenous community-based initiatives can also include programming aimed at pre-natal neurodevelopment in the context of exposure to substances such as alcohol or opioids, which suggests the focus might be ages −40 weeks to birth. And new developments in epigenetic research and maternal stress might expand the developmental window of interest from ages −two years to birth. Executive function, as an overarching conceptual framework which could encapsulate each of these developmental periods (and may also be relatively culturally neutral as a construct), would suggest the importance of consideration from ages −two years to 25 when prefrontal cortical development has completed (eg, particularly in the case of marijuana exposure). And, since our youth will someday have families of their own, we can expand these windows further in directions both backward and forward in time. What emerges is the need for an integrated conceptual model that can organize all of what is known into an accessible framework for developing and implementing what is needed for an individual, family and community to be well. Seven generations in both directions. Indigenous cultural knowledge holds this as true. What will be important in addition to improvement of systems and services in Indigenous communities is the ability of systems of service aimed at specific developmental age groups to be able to communicate and collaborate with adjacent systems. That is, infants become children who become youth who become adults who have infants. And, depending upon prevention and/or treatment effectiveness, it can be the case that an individual requires supports throughout her or his lifetime. Currently, it seems to be the case that in many jurisdictions these adjacent systems do not communicate as well as they ought to, and that our decision- and policy makers focus on their mandated developmental windows, sometimes at the exclusion of other developmental windows. This can result in gaps in service and care for those transitioning between demographics. Indigenous communities are working to improve their community systems of care. Eskasoni, for example, has developed a “womb to tomb” model of mental health which serves the whole community across the lifespan, thus improving continuity of care and ensuring issues related to re-referral, relationship building and aging-out of service are mitigated. The geographic context for Ulukhaktok reminds us additional challenges remain, such as the continued need for improved access to specialized mental health services. While system and service transformation is essential, at the same time, community-based initiatives aimed at stemming the effects of differential access to proximal, intermediate and distal determinants of mental health are required. Youth aged 11-25 years are to mental health treatment as children aged 0 to 6 years are to prevention. Indeed, in many Indigenous communities, ACEs are common and have significant developmental sequelae as demonstrated in the multitude of epidemiological studies published since the 1990s. For example, Dube et al. (2001) showed that an ACE score of at least 7 increased the likelihood of childhood/adolescent suicide attempts 51-fold (and adult suicide attempts 30-fold). With such massive effect sizes, the importance of system and service improvements cannot be overstated but neither can the importance of prevention. Perhaps nowhere is this so important as in Indigenous communities. Ambitious and necessary collaborations such as those between Eskasoni Mental Health Services, Ulukhaktok and ACCESS OM provide clear examples of how Indigenous communities and leaders in system transformation are working together to improve the lives of our youth. Dr. Mushquash is a Canada Research Chair in Indigenous mental health and addiction. His work was partially supported by the Canada Research Chairs Program. Dr. Mushquash currently sits on the Board of the Ontario Psychological Association. He receives no personal funding in this role and has no other potential conflicts of interest to declare.

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