Mental health implementation research in Indigenous communities: creating culturally safe space to enhance collective strengths

In this article, we discuss the construct of cultural safety in relation to the ethics, politics, and practice of implementation research in Indigenous communities. We convened a 3-day workshop, bringing together 23 Indigenous and non-Indigenous collaborators from First Nation communities and universities across Canada to reflect on experiences with implementing an Indigenous youth and family mental health promotion program in First Nation communities. Participants identified three dimensions central to achieving culturally safe space in implementation research: (1) interpersonal dynamics of collaboration between Indigenous and non-Indigenous partners; (2) structural and temporal arrangements necessary for collaborative work; and (3) the systematic recognition and incorporation of Indigenous cultural knowledge, values, and practices. Within implementation research, attention to cultural safety can mitigate the epistemic injustice that arise from research frameworks and methodologies that exclude Indigenous perspectives and values. Cultural safety can increase the likelihood that the research process itself contributes to mental health promotion.


Introduction
Over the past two decades, Canadian health research agencies have taken steps to address the historical injustices and colonial legacies faced by Indigenous populations in health services and research.There is now growing recognition of the necessity to develop culturally appropriate, strengths-based mental health programming and research that respects Indigenous knowledge, values, research endeavors that seek to develop and evaluate health interventions tailored to address the unique social, political, and ethical concerns of Indigenous communities (Canadian Mental Health Association, 2018;Crump et al., 2017).To advance this, there is a need to examine the actual processes involved in conducting research on Indigenous, communitybased, culturally relevant mental health interventions (Leske et al., 2016).
In this article, we explore some of the ethical, methodological, and interpersonal or relational demands of undertaking collaborative, participatory, mental health implementation research with Indigenous communities.Community and academic partners came together to reflect on lessons learned from their collaboration in the Listening to One Another to Grow Strong program (LTOA), a strengths-based, culturally grounded, family-centered, mental health promotion program, developed in partnership with First Nations communities across Canada, and designed for Indigenous youth and their caregivers (www.mcgill.ca/mhp).The project emphasized cultural safety in research, implementation, and program delivery.The experience of the team provided a unique opportunity to identify challenges and effective strategies in the creation of culturally safe space in implementation research.

Cultural safety in mental health research and practice
Developed by Māori (Indigenous people of Aotearoa New Zealand) nurses in New Zealand in the 1980s, the concept of cultural safety, responds to Māori experiences of nonrecognition, discrimination, and exclusion in health care settings (Koptie, 2009;Papps & Ramsden, 1996).Cultural safety goes beyond notions of cultural competence by focusing on power imbalances associated with differences in cultural identity, knowledge, language, and religion, as well as other aspects of institutional discrimination, colonization, and colonial relationships (Curtis et al., 2019;Kirmayer, 2012b).In Canada, cultural safety has been adopted by Indigenous and non-Indigenous organizations to guide strategies that address inequities in health care settings and institutions (Brascoupé & Waters, 2009;Cultural Safety Working Group et al., 2011).Given the historical suppression of Indigenous cultures due to state policies of forced assimilation, an explicit focus on the recognition of cultural identity, values, and practices in mental health services is paramount for many Indigenous individuals and communities (Gone & Kirmayer, 2020).
In research contexts, cultural safety aims to address the issue of epistemic injustice, which unjustly disadvantages or disqualifies individuals as knowledge holders and limits their ability to share knowledge without encountering doubt and disparagement (Fricker, 2007).Throughout Canada's history, epistemic injustice has silenced or marginalized Indigenous experiences, perspectives, and knowledge production, discrediting distinctive ways of knowing and excluding traditional knowledge systems in mainstream research.This can be understood as a form of epistemic violence (Spivak, 1994;Teo, 2010) or epistemic racism, in which standard methods of knowledge production and resulting knowledge products can cause harm and is clearly evident in the historical suppression and marginalization of Indigenous knowledge within research and clinical practice (Fraser et al., 2021;Matthews, 2017).This ongoing coloniality of knowledge, power, and being, is evident in the ways that Euro-North American perspectives continue to dominate and marginalize diverse knowledge systems, influencing resource allocation and determining what knowledge is considered legitimate (Adams et al., 2022).
The practice of cultural safety seeks to establish an environment that recognizes and respects Indigenous knowledge and experiences, including culturally grounded ways of knowing that may be woven into Indigenous community life and well-being, but that are often overlooked in conventional research approaches (Brockie et al., 2022;Kirmayer, 2012a).Achieving cultural safety in research requires acknowledging structural violence, disempowerment, and silencing of marginalized voices, and creating a collaborative space that is responsive to Indigenous peoples ' social, political, linguistic, economic, and spiritual realities (Blanchet-Cohen & Richardson/ Kinewesquao, 2017;Brockie et al., 2022;Colbourne et al., 2019;Greenwood et al., 2017;Kirmayer, 2012b).
Several ethical protocols developed in Canada address the rights of Indigenous communities when participating in research with institutions, contributing to the creation of a culturally safe space for Indigenous peoples in research.The CIHR et al. (2010) has produced guidelines for Indigenous health research, and the First Nations Information Governance Center has promoted the ethical principles of Ownership, Control, Access, and Possession (OCAP), which outlines formal research arrangements that can help prevent abuses of power by ensuring that Indigenous individuals and communities involved in research are protected and retain ownership over cultural knowledge and personal information (Schnarch, 2004).
Our present concern is with how such frameworks affect the dynamics of research as a relational process between individuals and communities.This focus is consistent with current discussions of relational ethics, which aim to move beyond the procedural ethics of research by placing emphasis on the quality of interpersonal relationships (Anae, 2016;Guillemin & Gillam, 2004).Relational ethics require taking the time to build meaningful and respectful relationships by paying attention to the lives of research participants, their histories, stories, and the communities in which they live (Gerlach, 2018;Guillemin & Gillam, 2004).Research praxis in Indigenous contexts takes this further by engaging with the sacred and spiritual dimensions of the research process (Anae, 2016;E. Kendall et al., 2011).Central to this approach is supporting openness, honesty, dialogue, and trust-building between all participating individuals, and consistent recognition of Indigenous ways of knowing (Datta, 2018;E. Kendall et al., 2011).

Implementation science in Indigenous contexts
Implementation science, a growing field that examines the methods and strategies to facilitate the uptake of evidence-based practices in real-world settings, holds promise for addressing mental health disparities in Indigenous communities (Kerkhoff et al., 2022;McIlduff et al., 2020).Increasingly, there is recognition of the importance of integrating Indigenous knowledge into evidence-based practice, as traditional Western approaches to evidence generation often overlook the valuable insights embedded in Indigenous knowledge systems.Indigenous knowledge aligns closely with the practice-based evidence approach, emphasizing learning from direct experiences, observations, and real-world practices (Ninomiya et al., 2022;Ninomiya & Pollock, 2017).By considering the unique social, cultural, historical, and environmental factors that influence health and well-being, implementation science within Indigenous contexts strives to bridge the gap between research and practice (McIlduff et al., 2020;Proctor et al., 2009).
Implementation research on Indigenous health programs and services can contribute to improving program development, planning, and delivery (Blue Bird Jernigan et al., 2018;Harding & Oetzel, 2019).Often such programs involve integrating culturally appropriate methods and strategies to promote the adoption of evidence-based interventions within specific Indigenous contexts.Implementation research in this context aims to identify the factors that facilitate or hinder successful implementation of programs and services tailored to the unique needs of Indigenous communities.The small scale, remote location, and resource constraints faced by many Indigenous communities pose obstacles to adapting programs or interventions originally designed to be delivered for urban settings.However, conducting research and evaluation of programs in Indigenous contexts presents specific challenges, including skepticism about the value of research itself (Koster et al., 2012;Ninomiya & Pollock, 2017), and divergent expectations between researchers and community partners for process and outcome (Chandna et al., 2019).
The study of cultural adaptation is a critical aspect of implementation science in Indigenous contexts.By introducing specific steps in the implementation process and carefully balancing intervention fidelity with local cultural fit, practitioners hope to ensure that interventions respond to the unique needs and preferences of Indigenous communities.Respecting and incorporating traditional health methods, cultural interventions, and community-led health initiatives may play a vital role in enhancing program effectiveness.Community engagement, collaboration, and cultural competence are essential elements when considering the adaptation and implementation of interventions in Indigenous communities (Brockie et al., 2022).
Implementation research with Indigenous communities raises specific challenges since it typically involves working with many communities that have their own protocols, constraints, and concerns that may impede adoption of a standardized intervention.Indigenous scholars have emphasized that research must recognize local cultural values and traditions in program implementation (Walker et al., 2015).To do this, the implementation process itself must be privileged over the products and outcomes of programs and services.
Participatory Action Research (PAR) is especially relevant in Indigenous contexts because it strives to encompass cultural, social, and contextual factors into implementation science by directly engaging community members within the research process (Goodyear-Smith et al., 2015;Israel et al., 2017).Many Indigenous communities have also developed their own evaluation frameworks to reflect the importance of culture and context in the evaluation process (Chandna et al., 2019;National Collaborating Centre for Aboriginal Health, 2013).While PAR approaches remain a gold-standard in community-based implementation research, scholars have noted that in under-resourced and under-served populations, implementation of services and programs are needs-based, and research is often viewed as a luxury due to its demands on financial and human resources (Brockie et al., 2022;Coser et al., 2021).Ensuring that cultural values, traditions, and priorities are central to the process of adaptation, implementation, and evaluation may increase the appeal of mental health programs to many communities, but it also raises specific challenges for the implementation process.Addressing these challenges requires going beyond the focus on cultural content to emphasize cultural protocols and processes.

The LTOA program
Developed in partnership with First Nation communities across Canada, the LTOA is based on an earlier Ojibwe (a group of Indigenous people in Canada and the USA) adaptation of the Strengthening Families Program for Youth (SFP 10-14) (Kumpfer et al., 2009).The Ojibwe adaptation of SFP 10-14, explicitly integrated Ojibwe language, cultural strengths, and teachings into programming to increase the effectiveness of SFP 10-14 for the Indigenous communities they were serving in the USA (Ivanich et al., 2020).In tailoring the program to the Canadian context, the primary objective was to further integrate traditional knowledge, values, and practices, to strengthen factors contributing to well-being (Kirmayer et al., 2016).LTOA supports First Nation partner communities across Canada in a process of local cultural adaptation and implementation.Through successive adaptations by diverse communities, LTOA has been modified to address specific community needs and priorities and to increase youth and family engagement.
In its current iteration, LTOA consists of 14 weekly 2-hr sessions delivered by local teams composed of Elders and community facilitators.Partnerships and close collaboration between community researchers, Elders, and university researchers is integral to the processes of program development, adaptation, delivery, and evaluation.Knowledge exchange in LTOA was guided by a Two-Eyed Seeing framework developed by Mi'kmaq (First Nations people from Atlantic provinces of Canada) Elders Albert and Murdena Marshall, as a means of bringing together Western science and Indigenous perspectives to inform health promotion and knowledge exchange (Bartlett et al., 2012).The aim was to approach the diverse perspectives of mental health and well-being of health professionals and Indigenous knowledge holders as complementary rather than competing in the creation and translation of knowledge (Colbourne et al., 2019;Peltier, 2018).This process was also informed by the work of Cree (North American First Nations people, that live primarily in Canada) Elder and Professor Willie Ermine on ethical space, which emphasizes the ethical, epistemic, and structural inequalities that must be addressed to insure equitable dialogue (Ermine, 2007).To move toward sustainability, LTOA aimed to develop a community of practice for Indigenous communities to support one another as they implement the program, with core values reflected in the creation of a shared safe space (Ninomiya & Pollock, 2017).
In 2019, the SSHRC of Canada provided grants to Indigenous communities and health research teams to consider how to address the TRC's Call to Action No. 65, for postsecondary institutions to work in collaboration with Indigenous populations to advance the understanding of reconciliation (TRC, 2015b).The TRC proposed that affirming and articulating the knowledge, values, and perspectives of Indigenous cultures in every sector of life must be central to the process of reconciliation (TRC, 2015a).In response, our research team received a grant to organize a workshop bringing together Indigenous and non-Indigenous partners from the program to reflect on successful strategies and obstacles at each stage of the implementation process, including adaptation, training, delivery, knowledge translation, and scaling-up.This article draws from those exchanges to explore the significance of culturally safe space in implementation research.

Methods
In February 2019, we organized a 3-day workshop in Winnipeg, Manitoba, bringing together 23 team members to discuss successful community-based program delivery and implementation research in Indigenous contexts.To encourage open dialogue between Indigenous and non-Indigenous partners, we used a Two-Eyed Seeing framework (Bartlett et al., 2012) and integrated Indigenous methodologies such as sharing circles and storytelling alongside Western methods.This allowed participants to explore not only the technical and practical aspects of program implementation but also the spiritual and emotional dimensions of their stories (Peltier, 2018).We made it clear to all participants that their involvement was voluntary, and they had the right to review and exclude their comments or contributions from the data analysis.Consent to include their contributions to the meeting was obtained from all participants.The meeting was audio recorded and three research assistants took detailed notes throughout the meeting.
We collaboratively established the workshop's objectives, protocol, and process at the beginning of the meeting.Before the workshop, an online form was sent to participants to identify discussion themes.Cultural safety emerged as a key focus identified by community partners.On the first day, we asked participants to reflect on four key questions: (1) What does cultural safety mean to you?; (2) What is the role of culture in creating culturally safe space?; (3) In your experience, with the LTOA program or other lines of work, how have you seen cultural safety applied?; and (4) Can you give examples of feeling "safe" or "unsafe" during program implementation?The research team encouraged participants to ground their reflections in their own experiences of community-based programs.
At the end of each day of the workshop, the research team, consisting of one postdoctoral fellow and three research assistants, coded and summarized the notes and recordings from the discussions.We used thematic analysis to identify patterns and recurring concepts (Guest et al., 2011).Codes were established through an inductive coding process, in which concepts that were raised in the discussions throughout the day were noted by the research team on a shared digital file.Research assistants then coded sections of the notes, and the codes were reviewed by the first author for consistency.Main themes were synthesized collaboratively with the research team.On the second day, we presented a summary of the first day's discussion to participants, seeking clarifications and specific examples to highlight key concepts.On the third day, we presented the meeting summary and analysis to the participants, who reviewed and reflected on the major themes that had emerged.Salient quotes from the audio recordings were used to support these themes, and the analysis was discussed with all workshop participants, who also reviewed drafts of the grant agency research report on which this manuscript is based.In the following sections, we expand on each theme and discuss its implications for promoting cultural safety in program implementation and research process.

Creating culturally safe space in the LTOA program
Participants used the notion of culturally safe space as an overarching metaphor to capture some of the essential ingredients for ethical, practical, and effective implementation research in Indigenous communities.Three interrelated themes emerged in the discussion of implementation research: (1) interpersonal dynamics of partnerships and collaboration between community researchers and non-Indigenous researchers; (2) structural and temporal dimensions of the project; and (3) the cultural dimensions of the project.

Interpersonal dynamics of the research collaboration
Workshop participants recognized the crucial role of interpersonal dynamics and the establishment of trust in university-community partnerships in Indigenous contexts (Bird-Naytowhow et al., 2017).Building trust in implementation research is essential for the process of planning, adapting, training, delivering, and evaluating interventions that resonate with communities and achieve intended health outcomes (Bird-Naytowhow et al., 2017).
In the LTOA program, trustworthiness among university and community partners was associated with four characteristics: respect, authenticity, openness, and flexibility.Workshop participants stated that these characteristics influenced the dynamics of the research relationship and the quality of the research.For many Indigenous communities, engagement with health research occurs against a backdrop of distrust of researchers and research institutions.Many workshop attendees described the troubling history of research in their own communities and shared stories of silencing, insensitivity, exploitation, or abuse by researchers.Decades of difficult and unrewarding experiences, paired with a wider history of cultural oppression, racism, and discrimination, have contributed to justified suspicion about whether community and personal experiences, viewpoints, knowledge, values, and questions will be heard and respected by research teams (Koster et al., 2012).
To address these deep-seated issues, implementation research requires a reflective and decolonizing approach to establish a culturally safe space.Since university research partnerships with Indigenous communities are vulnerable to issues related to conflicting agendas or priorities, inequities in resource access, and differences in cultural values and contexts, the research team needs to engage in reflective discussion with community partners to establish and maintain trusting relationships (Brockie et al., 2022;Chandna et al., 2019;Lauzière et al., 2022).Decolonization in research involves challenging the traditional power dynamics between researchers and communities through a commitment to joint learning, in which collaborative creation of knowledge recognizes Indigenous priorities, agendas, methodologies, and politics as key aspects of the research process (Bird-Naytowhow et al., 2017;E. Kendall et al., 2011;Kilian et al., 2019).In this context, fostering cultural safety also entails a process of un-learning, re-learning, and embracing the complexities and tensions that occupy the relational space and are inherent in transformation (Blanchet- Cohen & Richardson/Kinewesquao, 2017).Recent research has shown that the relational dimension is central to the promotion of cultural safety in complex intervention settings with longitudinal engagement (Lauzière et al., 2022).Workshop participants noted that building and maintaining authentic relationships requires ongoing engagement with community partners throughout the project's phases, characterized by transparency, truthfulness, compassion, and emotional openness.Previous research has emphasized the importance of self-awareness and critical reflection to understand how one's culture, identity, and beliefs impact the interpersonal relationships in diverse team and community settings (Dune et al., 2022).Ethical and epistemic frameworks like Two-Eyed Seeing need to be coupled with an attitude of active caring or loving-kindness to ensure that they are enacted in ways that foster trust, mutuality, and solidarity in the relational dynamics of the team (Sheppard, 2020).
In the case of the LTOA program, communities learned about the program from researchers with whom they already had long-standing relationships built on trust.In the early phase of the project, these pre-existing relationships were key to developing trusting partnerships across multiple project sites, bringing communities together with the explicit aim of fostering communication and acknowledging the unique histories, needs, and values of each community (Ivanich et al., 2020).
Project partners fostered respectful exchanges through explicit engagement with ethical guidelines and frameworks that emphasize Indigenous self-determination and community control over the program implementation and research process (Bird-Naytowhow et al., 2017;Brockie et al., 2022).In Canada, the First Nations Information Governance Center has endorsed the OCAP principles for the conduct of research in First Nations communities.Before beginning any research activities, all members of the research team received OCAP training.Community partners were also encouraged to share other local research principles and guidelines.One participant noted that the Mi'kmaw Ethics Watch (2000) provided an example of a community-created code of ethics.For Indigenous community partners unaware of these research principles, discussions took place to establish the relevance and importance of these guidelines and to identify how to integrate them with other mutually agreed on values and goals.Many workshop participants emphasized that respect and trust must be built over time in communitybased projects: How people learn to share, these are some of the little things that matter.We have built relationships [with the non-Indigenous researchers] that took time.As we got to know each other and hung out in Montreal [at the project's annual Two-Eyed Seeing evaluation meeting], we developed a level of trust.(Program Trainer, Ontario) University-academic partnerships are established within a context of historical and political processes, changing local priorities, and other community or personal events all of which require a flexible approach.Participants identified openness and flexibility as key characteristics that allowed individuals in the program to reflect on the relationships, needs, and preferences of the participants involved: If we are too focused on the curriculum of the program, we forget about our participants.People are so focused on delivering the program, you forget where people are at.Relationships are so dynamic.People get their needs met differently from each person.(Program Trainer, Ontario) Flexibility in the implementation process allowed program facilitators to respond to the needs of their groups during program delivery.The literature on implementation research has often considered the tension between the flexibility to tailor interventions to fit local contexts and fidelity to the key elements of the program associated with efficacy.The concern to include key components of a program often leaves little room for provider flexibility and decision-making in program delivery (Cohen et al., 2008).More recently, scholars have suggested that identifying the processes involved in key intervention components allows for greater flexibility which may be necessary to facilitate successful dissemination of evidence-based interventions in community settings (Bopp et al., 2013;Kendall & Frank, 2018).Flexibility in implementation research can enhance provider satisfaction, the delivery of the program, and program sustainability (Bopp et al., 2013).
For LTOA community partners, flexibility was not seen as secondary to program fidelity because many partners were concerned about how to adapt the program to their local context.One facilitator described having to change some of the content of the LTOA program, session on ceremonial practices, when they realized that some families and youth in the group were uncomfortable taking part in the smudging practices that were included in the program.These program participants felt that participating in a smudging ceremony would be in conflict with their own religious beliefs.Rather than encouraging these participants to follow the program content, the facilitator made it clear that individuals could decide which aspects of the module they were comfortable participating in and which aspects needed to be adapted to respect their values.By engaging in repeated discussions throughout the adaptation and delivery of the program, the research team was able to support community partners as they tailored the intervention to meet community needs, while maintaining core components of the program.The space for this dialogue and the flexibility in program implementation were demonstrations of trust and good faith that strengthened the partnership.
The interpersonal process of the research relationship is crucial to create and sustain a culturally safe space.The relationships fostered between community and university partners are not simply negotiated at the start of a project but must be maintained over time, nurtured through an ongoing process, based on mutual respect and explicit commitment to transparent goals, willingness to share power, attention to individual and collective positions, and openness to the ways of knowing and knowledge brought by community partners and program participants.

Structural and temporal dimensions
The structural and temporal dimensions of the research process emerged as another crucial aspect of culturally safe space.These elements are crucial for ensuring a supportive environment.Key components include having a secure physical location for work, reliable infrastructure, as well as strong local support for the program by individual and organizational champions.University research partnerships with Indigenous communities are vulnerable to various challenges such as conflicting agendas, inequities in resource access, and differences in cultural values and contexts.A decolonizing approach involves challenging the traditional power dynamics between researchers and communities, recognizing Indigenous priorities and politics (Bird-Naytowhow et al., 2017;Brockie et al., 2022).To achieve this, it is essential to establish and maintain clear guidelines and negotiated timelines.Furthermore, the physical spaces where programs take place should be carefully chosen by each community.These spaces should not be unduly influenced by external interests or pressures that could potentially affect the fairness, impartiality, and inclusivity of the interactions in that space.Workshop participants noted that the selection of a secure location instilled feelings of both physical and emotional safety, security, and support, while increasing participant engagement: Location has a lot to do with it [feelings of safety] and the physical boundaries that protect the space.Wherever you are going to hold the Program, you need to think about where to hold it.It can't be in the band office where everyone can walk in.People have angry feelings at band offices or parliament buildings.There is a lot of political attachment to those locations.(Program Trainer, Ontario) Workshop participants suggested it was important that research activities and program delivery are kept separate from local community politics or administrative agendas.Recognizing that spaces like government buildings and local band offices, where the administrative and political activities of First Nation communities are carried out, are often perceived as not neutral, teams should carefully consider how to conduct activities in a manner that avoids undue influence or bias in such settings.It is crucial to ensure that research activities and program delivery maintain their integrity, taking into account the potential impact of these spaces on the cultural safety of the interactions.The social meaning and dynamics associated with the specific places where implementation and research activities occur, as well as where programs are delivered, play a significant role in establishing a culturally safe space.
The temporal dimensions of research and program delivery also contribute to creating culturally safe space.In the LTOA program, the schedules, agendas, and format of meetings and events were negotiated among participants and researchers in advance to ensure that there was ample time for dialogue, and to attend to any pre-existing or emerging needs, concerns, or conflicts.Misunderstandings about deadlines and deliverables from granting agencies and research agendas can have long-lasting effects on community-researcher relationships (Brockie et al., 2022;Chandna et al., 2019).Fixed deadlines enforced by funding agencies may conflict with the process of dialogue involved in research and program delivery.Temporal flexibility poses particular challenges for researchers working within administrative frameworks that demand steady progress toward milestones on pre-established timetables.Program facilitators agreed that rushing program implementation or delivery could be detrimental to participants and the future of the program within the community: The way the program is set up . . .as the trust grows, you go deeper.It can only happen that way.You can't rush it.People are going to get hurt if you rush it.We have to be willing to do work without working.It is work that you cannot explain other than sitting and being.(Program Facilitator, British Columbia) The imposition of administrative or bureaucratic timetables is difficult in Indigenous communities for many reasons, one being that communities are often small and tightly knit.Since many LTOA program research partners come from the same communities as program participants, when a death or other traumatic event occurs in the region, program activities may be delayed or cease as the community responds: Anytime we are talking about changing programming that is evidence-based, in any community that whole concept of giving voice and choice is acknowledged.You did a good job giving us the space, but it is not always like that.There are times when researchers ask us why we open up with our emotions.We have different schedules.Things don't need to be time restrained.When that influx [of grief and other emotions] comes up, we don't need to be time restrained.(Program Facilitator, Nova Scotia) Other temporal considerations include ensuring that there is adequate time for individuals in a work group or conversation to process information, as well as to speak freely about personal or community needs and to clarify or negotiate meanings when shifting between languages and cultural contexts.Early on in the workshop, after an Elder spoke, one participant remarked that they would appreciate a moment of silence to truly process what had been said in their own language: Let's pause so we can catch up on our notes and understand what is going on.I automatically assume when it is a second language, we have to pause and think if what we are saying is safe to say.(Program Facilitator, Nova Scotia) Previous research has indicated the importance of understanding and interpreting communication cues including verbal, bodily and gestural language in maintaining cultural safety in health research and servicedelivery settings (Lauzière et al., 2022).Moving at a pace that respects the emotional significance of particular topics, as well as local protocols is crucial to maintain safe space.Doing so demonstrates commitment to building a culturally safe space in which the process of accessing Indigenous language and modes of understanding is valued and protected.Some authors have suggested that cultural safety can be created in shared research and service-delivery spaces by providing Indigenous-only time and space, where Indigenous language can be spoken without having to translate or broker meanings for non-Indigenous people (Firestone et al., 2019).However, there may be variation within Indigenous communities in levels of linguistic proficiency.Moreover, in mixed teams, creating separate spaces may lead to barriers in communication, divisive coalitions or splits in group process that may challenge collaboration.Maintaining safety in the large mixed group of researchers requires ongoing communication to ensure that team members share a common agenda, are apprised of issues related to joint work, and have a place to share perspectives and resolve conflicts.
Workshop participants concluded that there were important structural and temporal processes that contributed to the creation of a culturally safe space in the Program.Participants emphasized that the social structural dimensions of a setting defined, delimited, and ensured the safety of the physical space, while temporal features allowed participants the time to navigate, integrate, and maintain that space.

Cultural dimensions
Creating culturally safe space also requires identifying and respecting local ways of gathering and working together.This component was especially relevant given the diversity of the LTOA program team, which includes both Indigenous and non-Indigenous members from many different backgrounds.Within the LTOA program, culturally safe space was not simply a matter of physical security or respectful relationships, but included explicit connections to culture and spirituality.A culturally safe space was realized through the incorporation of Indigenous knowledge, spirituality, and an overall view of research as ceremony, in which symbolic and spiritual practices were integrated into research activities (Bird-Naytowhow et al., 2017).In practice, this integration meant incorporating cultural protocols and practices into project meetings and activities; for example, opening and closing ceremonies, smudging and prayer, and offering tobacco when knowledge was sought from Elders.These ceremonial actions served to create a sense of protection, focus and connection among team members, and led to an important shift in the ways that people listened and spoke to each other, with space and time for each person to fully articulate their ideas or concerns.
A key aspect of constructing culturally safe space in implementation research is understanding the diversity not just between Indigenous and non-Indigenous individuals, but also between and within Indigenous communities.The LTOA program encouraged each First Nations community to integrate their cultural knowledge, values, practices, and language within the program.Yet, there was substantial diversity of opinions about accepted cultural practices within many communities, particularly practices related to language, religion, and spirituality.Culture is not simply a shared set of knowledge, values, norms, and practices that are familiar to everyone, it provides resources that are used in different ways by individuals within a community.
Translating aspects of the program into the local Indigenous language is often part of the cultural adaptation process that aims to make the program material relevant for each community's context.The integration of language has contributed to the program's cultural safety, acceptability, and effectiveness.Indigenous language revitalization is a vehicle for strengthening the identity of Indigenous youths and their families (Taff et al., 2018).Although language was identified as a crucial cultural aspect of the LTOA program, there was recognition of the variability of both knowledge and comfort in using traditional languages across Indigenous communities: Many communities have those who are very comfortable with the language, or uncomfortable.Having space to work within a language is powerful.But the reality is that in many communities there is a big spectrum of people.If people do not know their language well, there is a lot of vulnerability.(Non-Indigenous Researcher, Quebec) Of course, culture is much broader than language alone, including core values and concepts about living a good life, life cycle transitions, worldviews, ceremonial practices, and practical knowledge about living on the land (Bourke et al., 2018;Fiedeldey-Van Dijk et al., 2017).For workshop participants, the opportunity to engage with their own culture and tradition was viewed as a key contributor to a sense of cultural safety, because of the acknowledgment of Indigenous values and collective identity.Yet, there was also recognition that cultural ceremonies may not be accepted by everyone.In diverse communities, facilitators had to include options for people to engage in their own practices with the common goal of coming together to work toward safety, open exchange, and mutual understanding.By acknowledging the diversity of both Indigenous and Western knowledges and methodologies in the research space, the LTOA team was able to be inclusive and accepting of all participants and establish and maintain a shared culturally safe space.

Conclusion
Through an intensive workshop reflecting on seven years of community experiences with a project culturally adapting and delivering a mental health promotion program, we identified three dimensions central to achieving culturally safe space in implementation research: (1) interpersonal dynamics of partnerships and collaboration between community researchers and non-Indigenous researchers; (2) structural and temporal contexts of the project; and (3) the cultural meanings of the project.
Addressing interpersonal dynamics was seen as an essential part of the overall research process especially during initial partnership formation.Building collaborative, mutually respectful relationships requires trust, which may be initially extended based on pre-existing relational networks but is strengthened and maintained by individual characteristics of respect, openness, flexibility, and authenticity.These characteristics are highly valued by both Indigenous and non-Indigenous partners alike and are cultivated throughout the planning, adaptation, implementation, and evaluation processes.
In the construct of culturally safe space, "space" is both a practical reality-requiring structural arrangements to find a place where work can unfold-and a metaphor for having adequate time and appropriate protocols to allow mutual recognition and reflection.The structural components of a space can evoke feelings of privacy, security, and confidentiality, with these physical elements facilitating a more literal understanding of a safe space.The opportunity to negotiate and adjust administrative deadlines to reflect community partners' needs and concerns is also essential to the construction of culturally safe space.Flexible timelines and agendas allow for life events to be honored respectfully, as well as providing time for reflection and engagement in the research process.
Attention to the cultural assumptions of intervention programs and of the process of research itself can open a space for dialogue with Indigenous worldviews, knowledges, and ways of knowing.This can directly address the epistemic injustice that has come from the suppression of Indigenous languages and cultures.Creating a culturally safe space for reclaiming and exploring Indigenous cultural knowledge, language, and practices during the process of implementation research can increase the likelihood that the research process itself will have beneficial effects.Approaching research as a dialogical process in culturally safe space opens the door to cultural exchanges that are the source of collective creativity both within and between communities.Erin Aleck is a member of the Nlaka'pamux from Lytton First Nation, and currently holds the role of Family Wellness Coordinator at Nlaka'pamux Health Services.She has also served as the LTOA regional program coordinator for the Nlaka'pamux nation.Erin played a central role as the main facilitator and researcher for "Zu?Zu?Twu?ix", the Nlaka'pamux version of LTOA.This 14-session program now incorporates essential Nlaka'pamux words, local histories, and traditions for youth and families.
Nicole A D'souza(PhD)  is currently a postdoctoral fellow at the Dalla Lana School of Public Health, University of Toronto.With over a decade of experience in youth mental health and community-based research, she specializes in adapting mental health programs and tools for diverse contexts.Her research focuses on leveraging cultural and social connections as protective factors against mental health problems for youth, especially those from equity-deserving populations.From 2016 to 2021, Nicole collaborated with the LTOA program, leading the evaluation research and working closely with community partners to understand how the program was implemented and adapted in various settings across Canada.Michaela Field obtained her Masters of Psychiatry from McGill University in 2023.Her expertise spans the fields of psychology, psychiatry, and participatory research.She previously worked as research assistant with the LTOA program, and has also partnered on a project with UNICEF to develop a toolkit on fostering and evaluating human dignity in humanitarian settings.Michaela is currently supporting an initiative identifying what elements of participatory research practices contribute to changes in health outcomes.Tristan Supino graduated from McGill University with a Masters in Psychiatry in 2022.For his Masters research, he worked collaboratively with Indigenous communities who were involved in the LTOA program to discuss concepts of "culture as cure."Tristan also worked with the LTOA program as a research assistant.Mia Messer graduated from McGill University with a Bachelor's of Science in Physiology in 2020.She worked as a research assistant on the LTOA program during her studies.Mia now works as a consultant in technical project management.
is James McGill Professor and Director, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University.He is a Senior Investigator at the Lady Davis Institute and directs the Culture & Mental Health Research Unit at the Institute of Community and Family Psychiatry, Jewish General Hospital, in Montreal, where he conducts research on culturally responsive mental health services, Indigenous mental health, and the philosophy of psychiatry.Laurence's publications include the co-edited volumes: Healing Traditions: The Mental Health of Aboriginal Peoples in Canada (University of British Columbia Press, 2008); Re-Visioning Psychiatry: Cultural Phenomenology,