Article Canadian Journal of Occupational Therapy

2019, Vol. 86(3) 220-231

DOI: 10.1177/0008417419832284

Indigenous perspectives on health: ª CAOT 2019

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Integration with a Canadian model sagepub.com/journals-permissions
www.cjotrce.com

of practice
Perspectives autochtones sur la santé : intégration des perspectives
autochtones sur la santé dans un modèle de pratique canadien

Dominique Fijal and Brenda L. Beagan

Key words: Canadian Model of Occupational Performance and Engagement (CMOP-E); Health knowledge, attitudes, practice; Indigenous
health services; Occupational therapy; Theoretical models.

Mots clés : Connaissances, attitudes, pratique en matière de santé; Ergothérapie; Modèle canadien du rendement et de l’engagement
occupationnels (MCREO); Modèles théoriques; Services de santé aux autochtones.

Abstract
Background. The Canadian Association of Occupational Therapists and the Truth and Reconciliation Commission recommend
change within the Canadian health care system, respecting and valuing Indigenous health and healing practices. Adjusting the lens
through which occupational therapists practice to incorporate Indigenous views of health and wellness is one potential change.
Purpose. This critical interpretive synthesis of the literature incorporates Indigenous perspectives on health and wellness into
the Canadian Model of Occupational Performance and Engagement (CMOP-E) framework, strengthening that model to better
serve all peoples in Canada. Key Issues. Integrating Indigenous worldviews can add to the CMOP-E the importance of balance
among physical, emotional, spiritual, and mental health; the inseparability of person, community, and land; and understanding occupations
as dimensions of meaning. These are incorporated in a proposed integrated model (ICMOP-E). Implications. Effectively integrating
Indigenous perspectives may be an important first step in a longer journey toward engaging more respectfully with Indigenous
perspectives on health and wellness.

Abstract
Description. L’Association canadienne des ergothérapeutes et la Commission de vérité et de réconciliation recommandent des
changements au sein du système de santé canadien, notamment de respecter et de valoriser la santé et les pratiques de guérison
autochtones. L’un des changements possibles pour les ergothérapeutes est d’envisager leur pratique sous un angle nouveau, afin
d’incorporer les perspectives autochtones sur la santé et le bien-être. But. Cette synthèse critique et interprétative des écrits
incorpore les perspectives autochtones sur la santé et le bien-être dans le cadre du Modèle canadien du rendement et de
l’engagement occupationnels (MCREO), consolidant ainsi ce modèle pour mieux intervenir auprès de toute personne habitant
au Canada. Questions clés. L’intégration des visions du monde autochtones pourrait permettre d’ajouter quelques concepts au
MCREO, comme l’importance de l’équilibre entre la santé physique, émotionnelle, spirituelle et mentale; le caractère
indissociable de la personne, de la communauté et du territoire; et la conception des occupations comme des dimensions du
sens. Ces concepts sont incorporés dans le modèle intégré proposé (MCIREO). Conséquences. L’intégration efficace des
perspectives autochtones pourrait être une première étape importante d’un long cheminement vers un engagement plus
respectueux face aux perspectives autochtones en matière de santé et de bien-être.

Funding: No funding was received in support of this work.

Corresponding author: Brenda Beagan, School of Occupational Therapy, Dalhousie University, P.O. Box 15000, Halifax NS, B3H 4R2. Telephone: 902-494-
6555. E-mail: brenda.beagan@dal.ca
Canadian Journal of Occupational Therapy 86(3)
We call upon those who can effect change within the
Canadian health-care system to recognize the value of
Aboriginal healing practices and use them in the treatment
of Aboriginal patients in collaboration with Aboriginal
healers and Elders where requested by Aboriginal patients.
(Truth and Reconciliation Commission [TRC], 2015, p. 163)
T
he Canadian TRC included health care in its calls to
action to engage all Canadians in a process of recon-
ciliation between Indigenous and non-Indigenous peo-
ples. The current reality that long-standing Indigenous
perspectives on health and wellness are not incorporated in
mainstream health care is just one of the reasons Indigenous
peoples in Canada experience poorer health status than the
Canadian average. In this article, we argue that theoretical
frameworks and models central to occupational therapy, which
arose from settler-colonial worldviews, may prove poorly sui-
ted to addressing Indigenous health and wellness. Re-visioning
foundational theories to effectively integrate Indigenous per-
spectives on health may help strengthen occupational therapy
approaches for all peoples in Canada. In keeping with United
Nations terminology, we use the term Indigenous to refer to the
original inhabitants of a territory. We use Aboriginal when the
term was used in original sources we are quoting, but in
Canada, that term links to a government-ascribed political sta-
tus (including First Nations, Métis, and Inuit), excluding many
groups who claim indigeneity to specific territories (see
Martin, 2012).
Calls to Action
Experiences of stigma, hostile treatment, discrimination, dis-
respect, culturally inappropriate care, and lack of understand-
ing in health care contexts (Browne & Fiske, 2001; Habjan,
Prince, & Kelly, 2012; Nesdole, Voigts, Lepnurm, & Roberts,
2014; Richmond & Ross, 2008, 2009) lead many Indigenous
people to avoid mainstream health care, where they do not feel
safe or respected (Health Council of Canada, 2012). This con-
tributes to the poorer health outcomes Indigenous peoples face
on multiple fronts (Gionet & Roshanafshar, 2013; National
Collaborating Centre for Aboriginal Health, 2012). The TRC
notes that the right to equitable health care is enshrined in the
United Nations Declaration on the Rights of Indigenous Peo-
ples and that treaties with the federal government recognize the
right to health care and protection from interference with tra-
ditional ways of life (TRC, 2015, p. 160). Calling on Canadians
to recognize and value Indigenous healing practices as one step
in providing more culturally competent services, the TRC puts
the onus on health professionals to better understand Indigen-
ous approaches to health and wellness.
In its recently updated position statement on occupational
therapy and Indigenous peoples, the Canadian Association of
Occupational Therapists (CAOT; 2018) encouraged occupa-
tional therapists to collaborate with Indigenous groups “to con-
tribute to health and social services” that “respect diversity in
how clients define meaning and prioritize needs and enable
engagement in everyday occupations using holistic approaches
221
to wellness” (p. 2). It also called on occupational therapists to
“advocate for, and contribute to, advocacy efforts and promote
the potential benefits of occupational therapy services” for
Indigenous people (CAOT, 2018, p. 2). To promote culturally
appropriate services, it may first be necessary to examine the
theories and models that guide practice.
Two-Eyed Seeing
In examining theory, we are guided by the concept of “two-
eyed seeing,” proposed by Mi’kmaw Elders Albert and Mur-
dena Marshall as a way of bridging two distinct and equally
valuable ways of knowing, or worldviews: Indigenous ways of
knowing and Western science (Bartlett, Marshall, Marshall, &
Iwama, 2015; Martin, 2012). Western science is characterized
by positivism, empiricism, objectivism, and reductionism (e.g.,
Hammersley, 2011). It assumes that there is only one reality
that can be observed and discovered, that scientific method
reduces or eliminates biases, and that complex phenomena can
(best) be understood by study on a smaller scale or lower level
(Hammersley, 2011). Western health care reduces the com-
plexity of human wellness to the sum of discrete parts and
processes, such as endocrinology, neurology, histology, and
so on. Practice emphasis is on curing illness or injury
and preventing chronic disease; from the vantage of many other
worldviews, this is a limited view of health and healing
(Martin, 2012).
Two-eyed seeing invites the viewer to simultaneously see
through two equally valid worldviews (Martin, 2012). It invites
active, respectful engagement with differing ways of seeing,
knowing, and understanding, for mutual benefit.
Learning to see from one eye with the strengths of Indi-
genous knowledges and ways of knowing, and from the
other eye with the strengths of Western knowledges and
ways of knowing, and using both these eyes together, for
the benefit of all. To date, two-eyed seeing has been
almost exclusively adopted by Indigenous scholars and
professionals to engage with Western modes of academic
inquiry and institutional systems. Few Western scholars
have employed two-eyed seeing to engage with Indigenous
worldviews. Yet Western occupational therapy can only be
strengthened by recognizing single-vision ways of knowing
as limited and partial and by incorporating alternative per-
spectives. When Westerners attempt to employ two-eyed
seeing, we must take into account existing power imbal-
ances in colonial contexts, which may impair our vision.
(Bartlett et al., 2015, p. 295)
The TRC calls on everyone in Canada to do the work of
reimagining relationships—to listen carefully and respectfully,
learning from perspectives that have too often been silenced. In
the spirit of two-eyed seeing, the CAOT’s position statement,
and the TRC’s calls for action, we suggest the need to reeval-
uate occupational therapy theoretical and practice models that
have derived from settler-colonial worldviews. (Settler coloni-
alism refers to a form of colonialism in which the colonizers
“settle” in the new country, displacing and even attempting to
Revue canadienne d’ergothérapie
222
eliminate the previous occupants; in contrast, franchise colo-
nialism extracts resources and exploits the Indigenous popula-
tions without occupying or settling the invaded territory;
Paradies, 2016.) Integrating Indigenous views of health and
wellness into prominent occupational therapy models, such as
the Canadian Model of Occupational Performance and Engage-
ment (CMOP-E; Polatajko, Townsend, & Craik, 2013), may be
a step toward ensuring occupational therapy meets the needs of
all peoples in Canada.
Neither author identifies as Indigenous; we both have
settler-colonial heritage. Our work with Indigenous commu-
nities has been limited. As such, we engage in this work as
allies, striving to follow the lead established by Indigenous
peoples. We are careful here to draw on ideas already published
in research with Indigenous communities, trying to identify
where there is existing consensus. It is our job as allies to
engage thoughtfully with such ideas, extending their challenge
to mainstream ways of thinking, encouraging ourselves and our
settler-colonial colleagues to rethink foundational ideas. The
TRC made clear that it is the responsibility of everyone in
Canada to work toward reconciliation.
In that spirit, this article critically reviews the literature to
explore similarities and differences between occupational ther-
apy views and Indigenous views of health and wellness in
Canada. There is a growing body of literature in occupational
therapy from around the world critiquing the theoretical
imperialism of the profession and pointing out how core ideas,
models, and practice assumptions arise from the unexamined
dominant worldviews of the Western world (e.g., Emery-
Whittington & Te Maro, 2018; Hammell, 2011; Hopkirk,
2012; Iwama, 2007; Thomas, Gray, & McGinty, 2011; Thorley
& Lim, 2011). Cultural safety has been embraced to guide
practice with Indigenous and Aboriginal clients, particularly
in New Zealand, where the term cultural safety originated, as
well as in Australia and Canada (e.g., Gerlach, 2012; Gray &
MacPherson, 2005; Jull & Giles, 2012). Critical reflexivity, a
sustained interrogation of our positioning (as individuals and as
a profession) within social, historical, and economic relations
of power, is emerging as an essential component of practice
with Indigenous communities (Gerlach, 2015; Gibson, Butler,
Henaway, Dudgeon, & Curtin, 2015; Nelson, 2007, 2009; Sted-
man & Thomas, 2011). In that spirit, we turn the critically
reflexive lens on a core practice model.
Any model of practice could (and arguably should) be
explored for its fit with Indigenous worldviews. For this initial
attempt, we focus on the CMOP-E as a model with solidly
Canadian origins that dominates practice in Canada. We also
focus specifically on the views of health and wellness detailed
by Indigenous people in Canada. While this limits the univers-
ality of our analyses, it already collapses multiple cultures and
peoples under the umbrella term Indigenous; at least by limit-
ing the focus to Canada, we can assume some commonality of
colonial experiences under a shared federal government.
Examination of practice models originating in other regions
should be explored in relation to the worldviews of peoples
Indigenous to those places. Here, in the spirit of two-eyed
Canadian Journal of Occupational Therapy
Fijal and Beagan
seeing, we propose an integration of Indigenous perspectives
into the CMOP-E to build on the strengths of this important
made-in-Canada model.
Searching the Literature
This article provides a critical interpretive synthesis (Dixon-
Woods et al., 2006) of the scholarly literature regarding Indi-
genous views of health and wellness in Canada. Ten databases
were searched using terms including health, wellness, attitude,
perception, Aboriginal, Indigenous, First Nations, and
Canada. Papers were retained if they detailed Indigenous per-
spectives pertaining to a broad definition of health, wellness,
and/or well-being. Papers were excluded if they focused on
health perspectives from non-Indigenous people and/or non-
Indigenous health professionals working with Indigenous peo-
ple, Indigenous perceptions of illness or specific conditions
(e.g., diabetes, cancer), the practice of occupational therapy,
or experiences with traditional healing. Dissertations were also
excluded. Seventeen articles were analyzed and synthesized,
all qualitative studies except one mixed-methods study and one
commentary. The study participants included Indigenous
youth, adults, and Elders from across Canada.
A thematic analysis was conducted by first identifying
themes and key findings from each study. Recurring over-
arching themes and associated subthemes were identified
and assigned codes that were then used to code each study.
Components of Indigenous health and wellness were intri-
cately intertwined, but themes were teased apart for pur-
poses of analysis.
Critical Interpretive Synthesis
Aboriginal health practices and beliefs, like Aboriginal peo-
ples themselves, are diverse. However, an holistic approach to
health is common to many Aboriginal cultures and has also
been increasingly validated by “Western” medicine. A belief
shared among many Inuit, Métis, and First Nation people is
that a sacred connection exists among people, the Earth, and
everything above it, upon it, and within it. For purposes of
healing, this means activities such as “on-the-land” or “bush”
healing camps where participants can experience the healing
power of the natural world. (TRC, 2015, p. 163)
In the literature reviewed here, the overarching themes
identified were balance, community, and land. Balance
involves physical, emotional, mental, and spiritual compo-
nents. Indigenous knowledge, culture, and identity were con-
sidered as part of the spiritual domain though interconnected
with community and relationship to the land (see Figure 1).
Health Is Balance
Though Indigenous cultures vary, in general, health tended to
be described as a balance among physical, mental, emotional,
Canadian Journal of Occupational Therapy 86(3)
Figure 1. Themes: Interpretive analysis of literature on Indigenous views of health.
and spiritual components (Isaak & Marchessault, 2008; Labun
& Emblen, 2007; Parlee, O’Neil, & Lutsel K’e Dene First
Nation, 2007; Richmond, 2015; Sasakamoose, Scerbe,
Wenaus, & Scandrett, 2016; Shea, Poudrier, Chad, & Atchey-
num, 2011; Stewart, 2008; Wilson, 2003). These four compo-
nents of health apply to health issues involving individuals,
families, and communities as well as the environment (Isaak
& Marchessault, 2008; Parlee et al., 2007; Shea et al., 2011).
Concrete examples of how balance may be achieved while
providing health services include having food in counselling
sessions, integrating ceremony or prayer in practice, includ-
ing Elders or traditional healers, and taking clients/patients
into nature or their communities (Stewart, 2008). Additional
characteristics identified as contributing to wellness include
self-respect, self-care, self-esteem, honesty, a sense of
humour, pride, identity, practicing traditions, spirituality,
and sobriety (Van Uchelen, Davidson, Quressette, Brasfield,
& Demerais, 1997).
Physical health. Healthy eating and availability of
healthy foods were described as components of physical health
(Sasakamoose et al., 2016; Shea et al., 2011). Some partici-
pants living in remote communities identified their ability to
eat traditional foods as an important aspect of physical health,
with dietary shift away from traditional foods viewed as nega-
tively affecting health (Adelson, 1998; Isaak & Marchessault,
2008). Access to traditional foods relied on access to land, the
health of the land, and the environment’s ability to support
healthy populations of animals and vegetation (Adelson,
1998; Harper et al., 2015).
In some studies, an active lifestyle was identified as impor-
tant to health, with decline in physical activity—partly due to
technology—diminishing overall health (Isaak & Marches-
sault, 2008; Shea et al., 2011). Physical activity was identified
223
as providing opportunities to exercise and socialize, helping
keep people on a healthy path and out of trouble, and providing
healthy coping mechanisms for chronic stressors (Sasakamoose
et al., 2016; Shea et al., 2011). Some identified traditional
activities, such as hunting, as important sources of physical
activity as well as opportunities to gain traditional cultural
knowledge (Shea et al., 2011).
In one study, physical needs, such as employment, a safe
living environment, being able to procure sufficient nutritious
food, being able to manage chronic health conditions, and
exercising on a regular basis, were identified as necessary for
health (Graham & Martin, 2016). In the current Canadian con-
text, basic physical needs of Indigenous peoples are frequently
compromised by inadequate material resources. Impoverish-
ment is caused by displacement from homelands, cultures, and
communities plus the shift from a land-based economy to a
wage-based economy (Nesdole et al., 2014).
Emotional health. Positive support and role models,
such as parents, grandparents, and Elders, were identified as
being important to promote emotional health (Isaak & March-
essault, 2008; Petrasek MacDonald et al., 2015; Sasakamoose
et al., 2016). Staying busy was linked to emotional health,
potentially leading to positivity, a sense of purpose, reduced
boredom and loneliness, and distraction from troubles, stress,
and negativity (Petrasek MacDonald et al., 2015). Some exam-
ples of activities identified in the literature as potentially con-
tributing to good emotional health were physical activities and
traditional activities, such as talking to Elders, participating in
sharing circles, and being on the land (Petrasek MacDonald
et al., 2015; Sasakamoose et al., 2016).
Mental health. Components of mental health and well-
ness identified in the literature included making “good
Revue canadienne d’ergothérapie
224
choices,” regularly and safely accessing and connecting with
the land, and being self-sufficient (Graham & Martin, 2016;
Harper et al., 2015; Isaak & Marchessault, 2008). Personal
outlook on situations, such as taking personal responsibility,
having a positive attitude, and helping oneself, was identified
as improving mental health (Graham & Martin, 2016). Some
examples of activities identified as contributing to mental
health were mental games, abstaining from drugs and alcohol,
and participating in continuing education (Graham & Martin,
2016; Sasakamoose et al., 2016).
Resilience, on an individual level and a community level,
was also identified as important to mental health. At the indi-
vidual level, resilience (the ability to come through hardship)
is enhanced by having strong coping and problem-solving
skills, a strong attitude of accepting change, and the capacity
to deal with past, present, and future challenges (Parlee et al.,
2007; Petrasek MacDonald et al., 2015; Van Uchelen et al.,
1997). Being embedded in a family, community, and culture
that embodies preparedness, adaptability, and resilience, as
well as collective capacity to deal with challenges, promotes
healing from the wounds of racism and colonialism (Parlee
et al., 2007; Petrasek MacDonald et al., 2015). A deep con-
nection to and respect for nature and the land were described
as foundational to adaptability (Petrasek MacDonald et al.,
2015). At the community level, connection to traditional ter-
ritory and knowledge of interconnections with land and other
species may strengthen resilience (Castleden, Garvin, & Huu-
ay-aht First Nation, 2009).
Spiritual health. “In the Native world, everything comes
from the heart” (Wilson, 2003, p. 89). Spirituality was
described in the literature as foundational to other aspects of
wellness and strength, an integral part of identity that needs to
be nurtured; it is lived in connection with everything and is
essential to healing (Castleden et al., 2009; Labun & Emblen,
2007; Parlee et al., 2007; Van Uchelen et al., 1997). Compo-
nents of spirituality include sacredness, faith, awareness of
interconnectedness, respect, religion, a belief in a higher
power, prayer, forgiveness, contact with Elders, and practicing
traditions and ceremonies, such as sweats and smudging
(Sasakamoose et al., 2016; Van Uchelen et al., 1997). This
crucial component of Indigenous health is typically ignored
or suppressed in current Canadian health care contexts
(Nesdole et al., 2014).
Indigenous knowledge and ways of life, Indigenous cul-
tures, and Indigenous identities were all identified in the lit-
erature as critical to health and well-being and may comprise
subthemes of spiritual health. Indigenous knowledge and
ways of life refers to ceremonies, traditions, and practices,
such as traditional land-based activities. Community Elders
play an important role in the transmission of such knowledge
and practices. Maintaining and transmitting Indigenous wis-
dom and practices have been identified as key to improving
and rebuilding individual, family, and community health and
well-being by promoting solidarity, social support, and par-
ticipation in land-based activities (Big-Canoe & Richmond,
Canadian Journal of Occupational Therapy
Fijal and Beagan
2014; Graham & Martin, 2016; Parlee et al., 2007): “Sto: lo
need to know their own teachings and culture in order to live
in an atmosphere of trust and community with others” (Labun
& Emblen, 2007, p. 213).
Indigenous cultures are inextricably linked to the land
and encompass traditions, practices, and knowledges that
forge collective values and identity, simultaneously promot-
ing health and wellness (Harper et al., 2015; Petrasek Mac-
Donald et al., 2015; Van Uchelen et al., 1997). Attending,
participating, and feeling connected to cultural and festive
ceremonies allow for a cleansing of the mind, body, and soul;
provides focus; and has been identified as an important health
practice (Graham & Martin, 2016; Sasakamoose et al., 2016).
Connecting to culture and participating in traditional practices
have been identified as protective factors that enhance mental
health and well-being, support physical and spiritual health,
and play a role in reducing substance use (Graham & Martin,
2016; Isaak & Marchessault, 2008; Petrasek MacDonald
et al., 2015). Communication with family, parents, and Elders
may provide opportunities to learn about culture and collec-
tive sources of well-being (Kral, Idlout, Minore, Dyck, &
Kirmayer, 2011; Sasakamoose et al., 2016).
Having a clear, strong Indigenous identity has been iden-
tified as contributing to wellness, strength, and maintaining
mental health (Stewart, 2008; Van Uchelen et al., 1997). In
one study, health or “being alive well” was understood as
“being Cree” (Adelson, 1998, p. 16). In another study, a Dene
participant said, “Health involves a lot of issues with identity. It
means respecting people and the land. A person should be able
to practice their Dene way of life” (Parlee et al., 2007, p. 123).
Though a component of spiritual health, cultural identity is
obviously interconnected with community (Stewart, 2008).
Community
If I am helping people out, and it can be in the most minor way
. . .it just allows me to feel connected to the rest of humanity. I
am doing my part. I am not just taking up space, I guess just
taking, period. (Van Uchelen et al., 1997, p. 43)
The literature suggests that health and wellness are reliant
upon community (Petrasek MacDonald et al., 2015; Shea et al.,
2011; Van Uchelen et al., 1997), which encompasses relation-
ships, social support, communication, and connections with
family, friends, and nearby others: “Loving others and having
others care for you is part of what makes you healthy” (Petrasek
MacDonald et al., 2015, p. 137). Community was identified as
essential for healing, mental health, emotional health and well-
being, operating through social relationships, increasing self-
awareness and personal growth, encouraging communication
and self-expression, giving hope, encouraging positive coping,
and feeling connected (Big-Canoe & Richmond, 2014; Graham
& Martin, 2016; Kral et al., 2011; Petrasek MacDonald et al.,
2015; Stewart, 2008). The ability to give to others is an impor-
tant aspect of the health-generating benefits of community:
“Being healthy is about, if you are successful you always give
Canadian Journal of Occupational Therapy 86(3)
a hand to the person beside you, and it is that sharing, that
source of interdependence, that has to happen for health and
healing to be present” (Stewart, 2008, p. 53).
A strong community with self-governance, good leader-
ship, youth participation, quality infrastructure and services,
and beneficial and sustainable economic developments was
identified as vital for health (Parlee et al., 2007). Intergenera-
tional community integration enables increased opportunities
for sharing, practicing, and preserving Indigenous knowledge,
especially out on the land (Big-Canoe & Richmond, 2014; Kral
et al., 2011). In some studies, participants identified lack of
support for Indigenous communities in Canadian contexts as
contributing to loss of wellness: “A lot of problems we are
seeing today are the result of people just working on their own
with no support from one another” (Parlee et al., 2007, p. 121).
The failure of non-Indigenous institutions to integrate mechan-
isms for cultural transmission and traditional teachings has
impaired the interrelationships among spirituality, cultural
integrity, and human development (Nesdole et al., 2014).
Land
“How can we be alive well if the land is not?” (Adelson, 1998,
p. 13). The land is central to, and interlinked with, individual
and community health and well-being (Adelson, 1998; Harper
et al., 2015; Nesdole et al., 2014; Wilson, 2003). It is a heal-
ing, nurturing, and spiritual place with physical landmarks
and sacred places that ground traditions and stories, convey-
ing balance and continuity (Labun & Emblen, 2007; Petrasek
MacDonald et al., 2015; Richmond, 2015; Wilson, 2003):
“Just as a church or mosque is a sacred place for some, a
particular forest floor, mountaintop, or river bed is sacred to
Huu-ay-ahts” (Castleden et al., 2009, p. 797). The land is the
cornerstone of Indigenous culture, knowledge, and identity
and an ideal place to pass on traditional knowledge and prac-
tices (Big-Canoe & Richmond, 2014; Harper et al., 2015;
Labun & Emblen, 2007; Parlee et al., 2007; Petrasek MacDo-
nald et al., 2015; Wilson, 2003). The health of humans is
understood as inseparable from the health of animals, other
life forms, and the land itself: “We are the land. If the land is
sick, then it isn’t going to be very long before we get sick”
(Richmond, 2015, p. 51).
Access to the land and land-based activities contributes
to the balance among physical, emotional, spiritual, and
mental well-being. It strengthens social cohesion and sup-
port networks; provides a platform for people to connect
with themselves, nature, each other, culture, identity, and
traditions; fosters important shared values; and allows tra-
ditional knowledge to be passed on intergenerationally (Cas-
tleden et al., 2009; Harper et al., 2015; Parlee et al., 2007;
Petrasek MacDonald et al., 2015; Wilson, 2003). An impor-
tant first step to addressing the legacy of colonization and
oppression experienced by Indigenous peoples in Canada is
to establish the context and structures for communities to
strengthen and rebuild connections with the land (Nesdole
et al., 2014).
225
Argument and Critical Discussion
To maximize the potential for two-eyed seeing (Bartlett et al.,
2015; Martin, 2012) to enrich the understandings of all, West-
ern worldviews must be open to re-visioning, encompassing
alternate ways of seeing. The purpose of this literature review
is to synthesize Indigenous views of health and wellness in
Canada, incorporating them in a reimagining of the CMOP-E
(Polatajko, Townsend, et al., 2013) to enhance the capacity of
that model to work with Indigenous and non-Indigenous peo-
ples. There is an inherent risk here: Given power imbalances
in colonial contexts, this entire endeavor may be assimilation-
ist, appropriating Indigenous knowledges for Western pur-
poses. Yet reconciliation relies on settler-colonizers
listening well and attempting to decenter dominant world-
views. This is our intent.
Similar to Indigenous perspectives of health and well-
ness, the CMOP-E eschews a biomedical model, viewing
wellness more holistically. Yet, it still tends to frame health
in terms of the individual; indeed, occupational performance
is conceptualized as a dynamic interaction among the person,
occupation, and environment (Polatajko, Davis, et al., 2013),
suggesting the person is separable from their environment. In
Indigenous worldviews, it would seem, the person is simulta-
neously their cultural, social, and physical environments.
Health and wellness rely on interconnected balance among
individual, community, and land. It may be that these differ-
ing views of the individual are irreconcilable. But minimally,
an integrated version of the CMOP-E could acknowledge not
only the health of the individual but also the health of the
community and the land, and the necessary connections
among these (see Figure 2).
Person
In the CMOP-E, the person is viewed as having three perfor-
mance components—cognitive, affective, and physical—with
spirituality at the core. Indigenous views of wellness also include
physical, emotional, mental, and spiritual health, but the empha-
sis is on balance among those; indeed, health is balance. As
described above, physical health requires access to healthy
and/or traditional foods, physical activity, and having physical
needs met. Emotional health is supported by staying busy and
having positive role models, while mental health requires a com-
ponent of resilience. Finally, spiritual health is enhanced through
accessing and practicing Indigenous knowledge and ways of life
and having connection to culture and identity.
In an integrated CMOP-E (ICMOP-E), the person is
symbolized as a circle, rather than a triangle, highlighting
the importance of balance among physical, emotional, men-
tal, and spiritual health, represented by equally sized quar-
ters of that circle. The dotted lines indicate that those four
aspects of health are interconnected in harmony. The circle
with the crossed lines also evokes the medicine wheel, val-
ued in many Indigenous communities, with four quadrants
symbolizing not only the four aspects of health but also four
Revue canadienne d’ergothérapie
226
Figure 2. An integrated Canadian Model of Occupational Performance and Engagement (ICMOP-E).
seasons, elements, geographic directions, and sacred plants
(e.g., Bell, 2014; Joseph, 2013; Silver Moccasin, n.d.)
Environment
In the CMOP-E, the person is surrounded by the environ-
ment (cultural, physical, institutional, and social). Indigen-
ous perspectives of the land could be seen as part of the
physical environment, with community as part of cultural
and social environments. This does not, however, reflect the
interconnectedness among individual, community, and land
or the importance of the health of community and land to
the person. To graphically represent the idea that commu-
nity and land are simultaneously part of the person, as well
as components of their environment, the ICMOP-E repre-
sents person, community, and land as a single circle with
gradually deepening shades from yellow to orange, to note
that community and land are both part of the person and
part of the environment. The outermost circle depicts the
Canadian context environment, a context with distinct his-
torical and current colonial relations and distinct governance
structures that shape occupational lives for Indigenous and
non-Indigenous peoples.
The ICMOP-E depicts the environment in interconnected
spheres: community, land, and the broader Canadian context.
Community includes family, relationships, social support, feel-
ings of connectedness, and infrastructure and services available
in the community. The land is a physical environment and is
interconnected with spirituality since it is fundamental to Indi-
genous knowledge, ways of life, culture, and identity. The
health of and access to the land have overarching influence
on community and individual health and well-being. The
Canadian Journal of Occupational Therapy
Fijal and Beagan
broader Canadian context includes the physical, social, cul-
tural, and institutional environmental elements of the current
CMOP-E. By locating these elements in the sphere of the
broader Canadian context in the ICMOP-E, there is a further
emphasis on how they affect the person who is interconnected
to community and land.
In the broader Canadian context, physical factors include
the location of the individual in community (remote/rural/urban)
and access to adequate and appropriate resources and services.
Social factors include the engagement of the Canadian public
regarding health inequities, the legacies of colonialism, treaty
negotiations, and responses to the TRC and the national inquiry
into missing and murdered Indigenous women and girls. Insti-
tutional factors include municipal, provincial, territorial, and
federal policies and practices that directly and indirectly shape
Indigenous and non-Indigenous occupations, such as procure-
ment of foods and medicines as well as health care experiences.
Cultural factors include the perspectives of health and wellness
embedded in health professional education and delivery, the
cultural lenses employed by health care providers; dominant
languages, values, and spiritual beliefs; and the secular, capital-
ist, and individualist emphases in Western cultures. As Paradies
(2016) notes, for Indigenous communities, increased presence of
“cultural factors,” such as “pursuit of land claims, economic and
political self-government, control over education, police, fire
and health services and the existence of cultural facilities” (pp.
89-90), correlates with improved health status.
Occupation
The core domain of interest for occupational therapists is occu-
pation, which is understood as a basic human need, affecting
Canadian Journal of Occupational Therapy 86(3)
health and well-being and bringing meaning to life (Polatajko,
Davis, et al., 2013). In the CMOP-E, occupations are categor-
ized as self-care, productivity, and leisure and are depicted as a
bridge between the person and the environment. Aspects of the
person and the environment affect ability to engage in
occupations.
The occupational categories of self-care, productivity, and
leisure have been criticized as endorsing values that reflect and
promote culturally specific political and economic agendas that
do not necessarily support well-being (Hammell, 2009, 2014).
It has been suggested that occupations might be better under-
stood, and occupational therapy theory and practice might be
more inclusive and more broadly relevant, if occupations were
conceptualized in relation to dimensions of meaning (Ham-
mell, 2009). This may facilitate fit with Indigenous world-
views, in which an occupation such as trapping might be
simultaneously about physical sustenance, spiritual wellness,
enjoyment, stillness, tradition, connection to community and
ancestors, and relationship to the land.
In keeping with this theoretical direction, the ICMOP-E
incorporates four dimensions of occupation that are based on
meaning rather than purpose: doing, being, becoming, and
belonging (Hammell, 2014; Rebeiro, 2001; Wilcock, 1998).
Doing is active engagement in occupations that are personally
meaningful. Being is the sense of who someone is—their spirit,
expressed through consciousness, creativity, and roles. Becom-
ing encompasses growth and change directed by goals and
aspirations. Belonging refers to contributing to others and feel-
ing connected to other people, places, cultures, community, and
nature. These dimensions of occupation are interdependent and
encourage holistic practice (Hitch, Pépin, & Stagnitti, 2014a,
2014b).
Instead of being a bridge between the person and their
environment, occupations in the ICMOP-E are ways to main-
tain balance among physical, emotional, mental, and spiritual
health and to connect with community and land. Occupations
are performed within a broader Canadian context. The health
and well-being of a person is shaped by their ability to engage
in personally meaningful occupations, which are themselves
influenced by the person’s access to, and the health of, their
community and the land.
In the ICMOP-E, occupation is graphically represented by
four triangles extending through person, community, land, and
Canadian context. These four triangles are connected by a ring
to show the interconnectedness of the four dimensions of occu-
pation. Since maintaining balance is central to Indigenous
health and wellness, occupational therapists may need to
remember that occupations may be chosen to achieve and/or
maintain harmony among differing aspects of self. Occupa-
tional therapists working with Indigenous people should
consider health of the community and land, as well as the
person, remembering they are interconnected. The broader
Canadian context, with its legacy of colonial relations, inevi-
tably influences and may hinder the health of person, commu-
nity, and land.
227
Serving All Peoples in Canada
Based on the literature reviewed, the ICMOP-E explores how
occupational therapy might better encompass Indigenous views
of health and wellness. In the spirit of two-eyed seeing, it may
strengthen the CMOP-E for all peoples in Canada, enhancing
our vision. In the current model, the person is described as
having physical, cognitive, and affective components, with
spirituality at the core. These person components are incorpo-
rated in the ICMOP-E as aspects of health and self, with an
emphasis on balance among them, highlighting holistic under-
standings of health and well-being. The emphasis on balance
might support occupational therapists to use a wider scope of
knowledge and skill with each client no matter their workplace
mandate. By focusing on using occupation to promote balance
within the person and among person, community, and land—
instead of emphasizing the impact of person components on
occupation—therapists may be able to provide more holistic
care. Moreover, the inclusion of community in the centre of the
model reminds therapists that “the client” is not always an
individual.
The CMOP-E describes spirituality as a person’s
“essence,” an ambiguous term that can be easily dismissed and
an aspect of professional practice therapists feel uncomfortable
addressing (Farrar, 2001). The ICMOP-E suggests a more tan-
gible definition: In addition to faith and sacred beliefs, spiritual
health is composed of relationship to culture, identity, and way
of life—which includes practices, traditions, and activities that
connect to land and ancestors, relating across generations. By
providing a more concrete concept of spirituality, and high-
lighting its importance by graphically portraying it as necessa-
rily balanced with other aspects of self and wellness, the
ICMOP-E may encourage occupational therapists to be more
aware of and attentive to client spirituality.
Polatajko, Davis, et al. (2013) describe occupation in the
CMOP-E as being the bridge that connects the person and their
environment. The strong emphasis on interconnections among
person, community, and land in Indigenous literature suggests
reconsidering the idea that the environment is something peo-
ple interact with or that influences occupation. Indeed, com-
munity and physical environment are part of the person. This is
worth exploring in non-Indigenous contexts, as well. Though
relationships between land and wellness may not seem as cen-
tral to non-Indigenous people, there are ways in which the
places we occupy shape and influence our identities, commu-
nities, cultures, and values. Whether our “land” is traditional
territory, a neighbourhood in an urban centre, a rural village, or
an online platform, we live in socially situated places that
become part of who we are. Geographers (e.g., Macintyre, Ell-
away & Cummins, 2002) distinguish between space (an
abstract measure of geography) and place (a concrete region,
large or small, that is imbued with meaning through the senses
and through interactions with others and with the land). Occu-
pational therapists attending to community and place for all
clients may unearth important considerations for occupational
performance that otherwise go unnoticed.
Revue canadienne d’ergothérapie
228
In the CMOP-E, social and cultural elements figure as
aspects of the environment that influence the person and their
occupations. In the Indigenous literature, culture and identity
are aspects of the person, the spiritual self. When culture is
understood not only as context but also as self, therapists might
better understand the depth of its impact on occupations for all.
By insisting that community and land/place are also compo-
nents of the person, therapists might better grasp how each
client’s wellness and occupations are shaped by the wellness
of their community and place in relation to the broader
Canadian context. This enables interrogation of the ways
individual wellness is affected by social relationships among
groups, such as those structured by power relations of race,
class, gender, and so on. It thus facilitates links to the social
determinants of health. The fact that the Canadian context is
rooted in settler colonialism allows the integration of a his-
torical dimension into understanding how social environ-
ments shape occupational meanings, engagement, and
performance.
Finally, the ICMOP-E emphasizes dimensions of mean-
ing—doing, being, becoming, and belonging—instead of occu-
pational categories of self-care, productivity, and leisure
(Hammell, 2009). This encourages occupational therapy in
Canada to move away from a system of categories whose rele-
vance may be partial, inadequately capturing occupations and
their meanings. Focusing on meaning facilitates more con-
scious attention to discovering personally meaningful activi-
ties, promoting the well-being of all clients. The CMOP-E
identifies occupational performance as the ability to do, in
relation to person, environment, and occupation. Occupational
engagement concerns interest, meaning, motivation, and invol-
vement. Clearly, in the ICMOP-E, these would centre on bal-
ance and harmony, interconnectedness, and dimensions of
meaning, as detailed above. But further speculating on how
occupational performance and engagement might be under-
stood differently through the ICMOP-E exceeds the scope of
this article, requiring further research with (and ideally, by)
Indigenous people.
Limitations and Strengths
There are important limitations to consider. This re-visioning
project inherently risks imposing colonial worldviews, as it
starts from an existing Western model that may simply remain
a poor fit for Indigenous perspectives of health. Power imbal-
ances make the risks of appropriation real. We have chosen to
focus on the CMOP-E because of its dominance in Canada, but
it may be that a less Western model would be more amenable.
We encourage others to explore the possibility of integrating
other models of practice with Indigenous perspectives; perhaps
there is a better fit. The centrality of the individual in the
ICMOP-E remains troubling, though we have attempted to
merge individual, community, and land. We assume the famil-
iarity of the CMOP-E among therapists in Canada is a benefit;
it is equally possible that adapting a model so familiar may
prove especially challenging. The intellectual exercise detailed
Canadian Journal of Occupational Therapy
Fijal and Beagan
here would need testing with Indigenous communities and with
therapists to ascertain utility in practice. Most importantly, this
model is not intended to provide a formulaic way of working
with Indigenous clients; as with all client-centered practice,
individual perspectives always need to be explored openly and
respectfully.
We have presented what may be a false consensus, given
the wide diversity of Indigenous peoples and cultures. Relying
on published literature is likely to miss important contributions,
as academic publishing may not be the ideal forum for Indi-
genous knowledge dissemination, and Indigenous scholars are
poorly served by academia. We have collapsed perspectives
from urban, rural, and remote communities as well as across
ages, genders, nations, and identities, where perspectives may
be substantially different. It is noteworthy that this model reso-
nates with many parts of the conceptual framework developed
by Hopkirk and Wilson (2014) based on research with Māori
and New Zealander therapists and health experts; there is a
major departure, however, in that their participants did not
identify occupation as significant; thus their framework
revolves around family and relationships. It is worth question-
ing whether our retention of the concept of occupation is a
cultural imposition.
Finally, we have employed two-eyed seeing here, balan-
cing Western and Indigenous perspectives. This implies a false
binary—there are other valuable worldviews worth consider-
ation. Yet Indigenous people are the group with which Canada
has an internal nation-to-nation relationship. This initial explo-
ration is one response to Indigenous calls “to see from one eye
with the strengths of Indigenous knowledges and ways of
knowing, and from the other eye with the strengths of Western
knowledges and ways of knowing” (Bartlett et al., 2015, p.
295). At the same time, it is just a start. Models of practice
do not alter deeply embedded colonial worldviews or racism.
They do not suddenly make health care services more acces-
sible to people living in oppressive conditions, including pov-
erty. They do not guarantee respectful practice. They do take a
step toward undermining the settler-colonial worldviews
embedded in dominant models.
The ICMOP-E may strengthen occupational therapy prac-
tice by integrating the perspectives of peoples Indigenous to
Canada, suggesting a more tangible definition of spirituality,
encouraging holistic care by emphasizing balance, deepening
client-centredness by conceptualizing the person as located in a
place and in community, and conceptualizing occupations as
dimensions of meaning. It could guide the development of
assessments that move away from self-care, productivity, and
leisure toward occupational meanings, balance, connections,
and resilience. In the spirit of reconciliation, perhaps incorpor-
ating Indigenous perspectives to a familiar practice model can
encourage the discussion and reflection on practice that are
needed in our collective movement toward reconciliation. Cul-
tural humility demands that we critically question practice
assumptions, laying bare structured relations of power.
Canadian Journal of Occupational Therapy 86(3)
Conclusion
This critical synthesis of the literature sought to better
understand Indigenous perspectives of health and wellness
in Canada and integrate these into the CMOP-E, strengthen-
ing this model to better address all peoples of Canada.
Though the CMOP-E and Indigenous perspectives share
some similarities, there exist significant differences, such
as the importance of balance among physical, emotional,
mental, and spiritual components of self as well as the
importance of interconnections among people, communities,
and land. Reconciling these differences in an integrated
CMOP-E might better serve Indigenous as well as non-
Indigenous peoples. To respond to the CAOT’s recommen-
dations and the TRC’s calls to action, more research is
needed to develop integrated theoretical models in occupa-
tional therapy. The integration we have proposed here is a
thought experiment developed by non-Indigenous scholars
based solely on available literature; collaboration with Indi-
genous communities is essential to evaluate appropriateness
and perhaps eventually develop assessments and approaches
to practice that reflect Indigenous worldviews. Canadian
occupational therapists working with Indigenous peoples are
armed with models of practice that do not reflect Indigenous
perspectives. Employing cultural safety is not enough; per-
haps it is time to revise the mainstream models, honouring
our past and reconciling with history while potentially
improving occupational therapy practice for all clients.
Key Messages
 Indigenous perspectives on health emphasize balance
among physical, emotional, mental, and spiritual compo-
nents as well as the inseparability of people, communities,
and land.
 Integrating these perspectives into the Canadian Model of
Occupational Performance and Engagement could
strengthen that model of practice for all peoples in Canada
while moving us toward reconciliation.
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Author Biographies
Dominique Fijal, MSc(OT), OT Reg (AB), is an occupational
therapist with Alberta Health Services.
Brenda L. Beagan, PhD, is Professor, School of Occupational
Therapy, Faculty of Health, Dalhousie University.
Revue canadienne d’ergothérapie