Co-Led Dialectical Behavioral Therapy Skills and Cultural Teachings for Perinatal Persons who are Substance Involved

Co-Led Dialectical Behavioral Therapy Skills and Cultural Teachings for Perinatal Persons who are Substance Involved | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Co-Led Dialectical Behavioral Therapy Skills and Cultural Teachings for Perinatal Persons who are Substance Involved Kristen Gulbransen, Geraldine Shingoose, Heather Ashdown, Heather Watson, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5321173/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study explored perinatal patient experiences in a co-led Dialectical Behavior Therapy (DBT) and Indigenous cultural teachings program. The aim was to understand the programs strengths, impact, and areas for improvement. Methods Guided by the Valuing All Voices Framework and using Appreciative Inquiry, interviews were conducted with participants (n = 9) and providers (n = 3) to capture their perspectives on participating and facilitating in the co-led session. Results The DBT and Indigenous cultural teachings, co-led by an Indigenous Knowledge Carrier and a Psychiatrist, were presented through a strengths-based approach. Participants engaged with the teachings across the four sessions, which fostered increased hope, emotional regulation, and resilience. They also developed better coping skills, recognized the importance of their self-identity, and strengthened their positive connection to their culture. Conclusion The study illustrates a promising DBT and cultural teaching approach for integrating culturally appropriate teachings within perinatal mental health care, responding to calls for Truth and Reconciliation, and addressing health disparities. substance use perinatal dialectical behavior therapy cultural teachings Figures Figure 1 Introduction Interest in pregnancies affected by substance use has increased significantly over the past five years, driven in part by the mental health and social-welfare crises exacerbated by the COVID-19 pandemic [1, 2, 3, 4]. Much of the emerging literature highlights the severe obstetrical outcomes for parents experiencing psychosocial instability during pregnancy, including preterm birth, fetal growth restriction [5], maternal sepsis, and mortality [6]. These outcomes are often worsened by insufficient prenatal care, stigma, and systemic marginalization, leading to rates of postpartum depression that are more than three times higher in this population [7]. Alarmingly, one in five maternal deaths in Canada is the result of overdose or suicide, and these rates are increasing [8]. In parallel, an emerging body of literature has articulated the disproportionate suffering of pregnant individuals from Indigenous communities in Canada, who face up to four-times the rate of maternal death compared with non-Indigenous counterparts [9]. The enduring impacts of colonization manifest in unattended birth [10], inflated rates of HIV and diabetes [11], and overrepresentation in child apprehension for Indigenous parents [12, 13]. The intersection of risk is multiplicative. For example, one quarter of women/parents with psychosocial comorbidities during pregnancy will develop postpartum depression [7], and one in seven individuals will experience an overdose within one year of birth [14]; if they are also Indigenous, these already high rates double [15]. Although it can be easy for some to view these individuals as unfortunate statistics, pregnancy is also a time of tremendous transformation, hope, and community connectedness [16]. It has higher rates of substance-use stabilization [17], care-engagement, and the initiation of social support [18] than any other time in adulthood. Pregnant individuals with psychosocial comorbidity also demonstrate resilience, and inventiveness, and are motivated to improve maternity care. Similarly, Indigenous tradition is itself a source of strength. The integration of cultural practices during pregnancy and birth respects and honors the traditions, beliefs, and practices of diverse communities, fostering a sense of trust and comfort [19, 20] . While most of these studies conclude that interprofessional, holistic care strategies are required, operational guidance is lacking and the healthcare system in Canada is heavily colonized. The World Health Organization (WHO) identifies culturally appropriate maternity services as central to their global strategy for enhancing maternal and newborn health and eliminating preventable maternal mortality [21], but there are few examples to draw from to transform care practices to be destigmatized, decolonized, and dignified for these families. Background The Interprofessional Psychosocial Maternity Care (IPMC) team, located in inner-city Winnipeg, Manitoba, Canada, is a collaborative practice comprising obstetrics, midwifery, psychiatry, nursing, and social work, with opioid agonist therapy (OAT) included within their scope of services. The IPMC is situated in Treaty One Territory, and the many First Nations and Metis in Manitoba share cultural-linguistic heritage with the Anishinaabe (Ojibwe), Ininew (Cree), and Dakota peoples [21]. The IPMC providers deliver care to pregnant individuals with psychosocial comorbidities through clinic visits, virtual appointments, and home or shelter-based visits and support. Their approach aligns with the WHO principles for managing substance use in pregnancy, emphasizing access to prevention and treatment services, respect for autonomy, comprehensive care, and the development and implementation of safeguards against stigma [22]. The IPMC clinician providers, identified as settlers, partnered with local Indigenous scholars and Knowledge Carriers to collaboratively develop the co-led Dialectical Behavior Therapy and Cultural Teachings sessions and research project. Table 1 outlines the research team roles, inclusive of the providers self-location. Table 1: Researcher team self-location & team role Person Self-location Role Gramma Shingoose Knowledge Carrier Aanin, Boozhoo I am Anishinaabe Ikwe from Tootinaowaziibeeng Treaty Reserve, Treaty 4 Territory. My spirit names are Sky Woman, Northern Lights Woman and I come from the Bear Clan. My English name is Geraldine Shingoose. As a Matriarch Grandmother/Great Grandmother, I am strongly connected to the community, continue to work fearlessly on search the landfill, have a lifelong commitment to learning under the direction of Indigenous Elders, and a commitment to my cultures’ practices. Health care practises have brought harm to Indigenous peoples when they seek health care. My participation in Health research has brought me hope in my vision to bring change, and to decolonize health care system. By bringing in Indigenous Strength based practises into Health research and into health care practice. Ekosi. Co Leader Cultural Teaching Facilitator Heather Ashdown Psychiatrist I have a settler background including primarily British and German origins. I have been significantly advantaged as a white settler in the context of the ongoing genocide against Indigenous people in so-called Canada. I work to dedicate myself in my work and personal life to meaningful and action-based solidarity with Indigenous peoples and also with other BIPOC people who continue to be harmed by systems that uphold white supremacy. Co Leader DBT Facilitator Heather Watson Psychosocial Obstetrics Gynecologist I am an uninvited settler of primarily Scottish heritage; my family arrived in Canada as orphan "Homestay" children, shipped to southern Ontario to serve the wealthy British families who were established there. I also am descended from those wealthy British lines. My own children have Indigenous heritage which includes the Red River Metis and Blackfoot Cree Nations; I grieve the injustice their ancestors endured at the hands of mine. They have allowed me to companion them as they connect with these legacies as young adults, as I walk my own path towards reconciliation. Clinical Lead Kristen Gulbransen, RN PhD I am an uninvited settler with Ukrainian, German, and Norwegian background. At the time of this research, I was a postdoctoral student under the supervision of a non-Indigenous Midwife working as a provider and researcher in this clinic committed to working toward Truth and Reconciliation. I am committed to actionable work to decolonize the system and recognize the harms that need to change. Research Interviewer & Coordinator Kellie Thiessen, RM RN PhD I have a settler background and am a visitor to Treaty 1 Territory in Manitoba. As a white settler I acknowledge that I have unearned privilege in the context of a system that continues to perpetuate harm against Indigenous and BIPOC persons. I am committed to ongoing work in allyship alongside Indigenous communities so healing and reconciliation are the focus of our work together. Principle Investigator, Research Lead Key principles of DBT include mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness [23]. The DBT has been shown to help decrease substance use and overdose rates, suicidal ideation, and depression symptoms [24]. DBT is also beneficial for individuals who have experienced trauma and intimate-partner-violence survivorship, making it particularly valuable for the majority of IPMC patients. The dialectical approach in this therapy integrates the perspectives of the Intelligent Mind and the Emotional Mind in service of a Wise Mind. The principles of balance dovetail nicely with the Anishinaabe teachings of the Four Directions in which spirit, body, heart, and mind seek harmony within the self [25]. The resulting program, adapted for the perinatal population, was co-led by a settler psychiatrist and Indigenous Knowledge Carrier, and provided in a group therapy format. It was called “Perinatal Co-Led DBT” and participants were invited to attend four one hour sessions (see Figure 1). We aimed to explore the patients’ experiences of the co-led DBT and Indigenous cultural teaching sessions, its strengths, and their perceptions of the impact of co-led sessions. The Valuing All Voices Framework guides our on-going work with the population that we serve as it embodies social justice and a health equity lens in qualitative research[26]. This framework encompasses five key concepts: 1) Education and Communication, 2) Understanding and Acceptance, 3) Trust, 4) Relationship Building, and 5) Self-Awareness. The history of research involving Indigenous peoples in Canada is complex and deeply intertwined with the broader history of colonialism, cultural assimilation, and the struggle for Indigenous rights [27, 28]. This history is marked by periods of exploitation and neglect, and, but in recent years there have been efforts toward reconciliation and collaboration have been made [28]. Our team is advancing the interprofessional care approach and research by adapting DBT in a high-risk perinatal population and responding to the Truth & Reconciliation Calls to Action [29]. Methods Indigenous engagement process We believe that meaningful engagement with Indigenous individuals is the first step toward a shared journey. Therefore, we aimed to engage Indigenous scholars and Knowledge Carriers in a respectful, honest, and humble way. We also started with the truths that Indigenous pregnant women are more likely to develop clinical complications during pregnancy than non-Indigenous pregnant women are [12] and that this is due to the ongoing harms of colonialism and Indigenous racism [29]. Furthermore, most of our patient population at the IPMC is identified as Indigenous. The team aimed to develop a therapeutic intervention that combines Indigenous Ways of Knowing with evidence-based therapy (DBT), prioritizing co-creation with patient input. Integrating cultural practices in maternity care can empower families to connect with their identities during the perinatal period, leading to decreased experience of postpartum depression, and reduced rates of preterm and low birthweight infants. Conventional addiction treatment often views the self as weak, and a source of shame, whereas Indigenous healers value the self as a source of pride with a link to intergenerational strength [30, 31, 32]. Incorporating Indigenous healing practices into medical care has been identified as an essential element of Reconciliation [12, 29, 33] and has been experienced as restorative medicine during pregnancy. The IPMC actionable clinic goals recognize the necessity to engage Indigenous Elders, Grandmothers, and Knowledge Carriers in the research process. We recognized Indigenous involvement as essential in conducting respectful, relevant, and impactful research with Indigenous communities. We were aware that researchers must approach this engagement with humility, respect, and a commitment to genuine collaboration. We followed steps of engagement based on Indigenous scholars [28]. Table 2 outlines how our team engaged and partnered with Indigenous Knowledge Carrier as both a research team member lead and a co-facilitator of the co-led DBT and cultural teaching sessions. Table 2 Steps for Engaging Indigenous Knowledge Carriers in Research Early and Ongoing Engagement • Initial meeting in Assiniboine park before research study planning. Invitation to Knowledge Carrier to be a research lead and co-facilitator. • Involved Indigenous researchers from beginning by co-designing the study. DBT skills sessions were adapted to cultural teachings. • Had a point person on the research team for Indigenous knowledge carrier to connect with regarding protocols and ask any questions. Building Relationships • Frequent communication, open and honest conversations throughout the study. • Elder/knowledge keeper holds leadership position in all stages of the research study and during the DBT and cultural teaching sessions. • Participants invited to Assiniboine Park for closing ceremony of the study. Respecting Protocols • Offered tobacco before study planning commenced. Holding a pipe ceremony to open and close the study. • Gathered Indigenous sacred medicines for teachings in a respectful way for the sessions and ceremony. • Advocated for dedicated funding and paying honorarium in a timely way. • Provided food from local Indigenous restaurant at request of Indigenous Knowledge Carrier. Collaborative Research Design • Respect and honored the Indigenous ways of research (oral teachings offered during sessions, open ended flexible interviews). • Followed OCAP (ownership, control, access, and possession) principles. • Incorporated Indigenous oral teachings in the DBT and cultural teaching sessions and research team meetings. Reciprocity • Contributions of Knowledge Carrier highlighted throughout project. • Met regularly and refine strategies to ensure the sessions remained effective and respectful. Had a giving and receiving relationship. • Ensured that Indigenous research members had access to necessary resources (transport to sessions, study resources). Knowledge Translation • Promote ways to acknowledge the work Knowledge Carrier Shingoose offered (highlighting in publications, program proposal, discussions with other providers). Appreciative inquiry We employed Appreciative Inquiry as a qualitative research method, conducting interviews with both participants and providers. Appreciative inquiry is a strength-based approach that focuses on strengths and opportunities for improving care [32]. When utilized as a research method, appreciative inquiry is a generative process focused on positive ways to explore, discover, and transform systems [34]. Identifying strengths can yield actionable ways to promote best practices in health care systems [32]. Our aim was to use a research approach that would limit unintentional retraumatization while highlighting the strengths within the patients and the existing system. Embedded in critical social theory, appreciative inquiry supports an open dialogue wherein people at the point of care are encouraged to engage in practice development to improve their setting and experiences [35]. Ethical approval was obtained from the University of Manitoba Health Research Ethics Board and the Shared Health Ethics Committee. All participants provided written or verbal consent. The decision to use appreciative inquiry as a method was well supported by the research team and ethics review boards. Engaging patient participants was essential to ensure that priorities from the patient perspective were at the forefront. Study context: Co-led DBT skills and Indigenous cultural teachings We adapted and implemented Dialectical Behavior Therapy (DBT) skills sessions for pregnant individuals with psychosocial comorbidities, on the basis of Dr. Marsha Linehan’s DBT Skills manual [23]. Our adaptation incorporated cultural teachings delivered by an Indigenous knowledge carrier/Grandmother team member. The DBT sessions were co-led by an Indigenous Knowledge Carrier/Grandmother and a psychiatrist. Knowledge Carrier/Grandmother Shingoose was the Indigenous knowledge carrier with a deep cultural knowledge of traditions, stories and ceremonies and Dr Ashdown focused on perinatal mental health. Table 3 provides an overview of the session topics. Table 3: Co-Led DBT skills and Indigenous Cultural Teaching Overview Week Indigenous Cultural Teachings DBT skills teaching Week 1: Spiritual Health Cedar teachings Mindfulness DBT Skills Week 2: Emotional Health Sage teachings Emotion Regulation DBT Skills Week 3: Mental Health Tobacco teachings Emotion Regulation and Interpersonal DBT Skills Week 4: Physical Health Sweetgrass teachings Distress Tolerance DBT Skills Our approach to care is grounded in the belief that integrated care is inherently more holistic and that prioritizing spiritual wellbeing is not in conflict with medical care priorities. Our adaptation to DBT includes the following rationale: Incorporation of Indigenous medicine is grounded in the self as a source of strength and pride. In contrast, addiction treatment is often grounded in self as a source of weakness and shame. Co-led integrated care is inherently more holistic . Prioritizing spiritual wellbeing and cultural teachings is not in conflict with medical care priorities. DBT being adapted to the perinatal period and partnered with Indigenous specific curricula from the Knowledge Carrier/Grandmother on our team is responsive to the TRC work. During the perinatal period more than any one time in the life course, pregnancy is a catalyst for change. Who we are as individuals, in our communities, as sacred water carriers all collide in pregnancy. DBT leverages willingness in pursuit of a more sustainable way to cope with life's challenges. Sampling We worked collaboratively to establish inclusion and exclusion criteria prior to recruitment. The inclusion criteria were as follows: patients who have their own agency and decision-making power over their health care and are antepartum or up to 12 weeks postpartum at the time of patient invitation. We did not engage minors, nor did we engage patients who were psychologically or physically unstable. We prioritized a representative group of patients which included Black, Indigenous, and People of Color (BIPOC), and represented the IPMC clinic population. The team of clinicians screened patients prior to any initiation of engagement with these inclusion criteria as their guide. The obstetrician and psychiatrist who provided care at the clinic contacted patients at the end of their routine appointments to invite them to participate in the co-led DBT skills and Indigenous cultural teaching sessions. They obtained consent to contact for the research interviewers (KT, KG) who then obtained informed consent. Participation in the study was not a requirement for attending the co-led DBT and cultural teaching sessions. All potential participants were given a copy of the research consent form to review prior to the interviews, and a Pledge of Confidentiality was signed before participation. The IPMC providers invited 12 patients to participate in the DBT skills and Indigenous teaching sessions. Three participants chose to defer participation during the spring sessions, while nine participants signed up for the sessions and completed the pre-interview. Out of those, seven participants completed the post-interview. The two participants who did not complete the post-interview did not attend any of the sessions and opted to defer their participation in the DBT and cultural teaching sessions until a later date. Additionally, three individual interviews were conducted with the IPMC providers and the Indigenous knowledge carrier. Data collection Semi-structured interview guides were designed for pre interviews conducted 1-2 weeks before the DBT and cultural teaching sessions. Post-interviews occurred 3-6 weeks after the sessions with participants. Input on the interview guide was sought from an Indigenous scholar, Indigenous Knowledge Carrier, and appreciative inquiry expert. This collaboration aimed to keep the questions strength based and relevant to the study aim. Each interview followed the 4D model of appreciative inquiry; Discovery, Dream, Design and Destiny [36, 37]. In the Discovery phase, the focus was on soliciting participants' perspectives on the DBT and cultural teaching sessions. The Dream phase invited participants to share their visions for improved care experiences during these sessions. In the Design phase, participants were encouraged to provide actionable ideas on how providers and the healthcare system could support and sustain the ideal care experience. Finally, the Destiny phase explored realistic strategies for enacting and sustaining the DBT and cultural teaching sessions. Questions were designed to elicit participants’ views on what they hoped to achieve from the sessions, what aspects they found most valuable and practical for their daily lives, and suggestions for program improvement. The semi-structured interviews were conducted by two researchers (KT, KG) with participants via telephone and with the IPMC providers via video meetings. Data were audio recorded and transcribed verbatim. The transcripts were checked for accuracy by the research team. Analysis Data were analyzed following appreciative inquiry which focuses on making sense of the data through the lens of participants’ experiences and perspectives [37, 38]. We adopted the appreciative inquiry approach because it can facilitate positive change in systems by identifying existing strengths and opportunities for future improvement. Research team members convened from May 2024 to July 2024 to analyze the data. We read the transcripts in their entirety multiple times to gain an overall understanding and identify keywords or phrases that would form codes, themes, and subthemes [38]. A reflexive stance was adopted, with researchers demonstrating self-awareness by acknowledging their positionality and examining their own thoughts, feelings, and actions throughout the research process [38]. Examining the context of the co-led DBT and cultural teaching sessions aided us in identifying and exploring what is important to participants and what made participating possible. Patterns and consensus on the strengths and logistics of the sessions were identified during review of the data. In this article, we present quotes without any participant identifiers or use of pseudonyms from all seven participants. Findings The IPMC providers invited 12 patients to participate in the DBT skills and Indigenous teaching sessions. Nine participants signed up for the sessions and completed the pre-interview, and seven participants completed the post-interview while 3 deferred to attend sessions outside of the study timeframe. All patient participants met inclusion criteria for the study and represented both prenatal (n=5) and postpartum (n=4) patients, Indigenous (n=7) and non-Indigenous (n=2). Additionally, three individual interviews were completed with the IPMC providers (obstetrician, psychiatrist, and Indigenous Knowledge Carrier). This study revealed a number of outcomes for the patient participants related to attending the co-led DBT and Indigenous Cultural Teaching sessions. These were shared throughout all stages of the 4 D’s and themed as follows: hope, increased emotional regulation and resilience, increased coping, recognition of the importance of their own self-identity, and positive cultural connection. There were also unintended outcomes for the providers. They described the sessions as significantly increasing their job satisfaction, as the antidote to burnout, and as actionably responsive to Truth and Reconciliation [29]. We followed the 4Ds of Appreciative Inquiry to present the data/participants’ quotes. Discovery The responses during the pre-interview with participants revealed that hope was at the forefront of the sessions. The participants expressed optimism that the sessions would provide teachings on emotional regulation, coping techniques, spiritual health, and self-identity in the pre-interview. The participant responses from the discovery phase during the post interview confirmed that the sessions met their expectations related to emotional regulation, coping techniques, and self-identity. Participants described the best parts of the DBT and Indigenous teaching sessions as “I have more coping skills… because of both of their teachings” and “reminded spirituality is embedded in all that I do.” Participants provided further comments that the most valuable aspects of the co-led DBT and Indigenous teaching sessions with comments such as, “ I was reminded that spirituality is embedded in all that I do. ” They emphasized the significance of having co-led sessions, noting that “ seeing and having Dr. Ashdown and Gramma work together, and having it all planned out together ” was one of the highlights that “ made a difference.” Storytelling by the co-leaders was particularly well-received. Gramma Shingoose shared stories of resilience, grit, parenting, surviving residential school, and cultural teachings. The perinatal psychiatrist, Dr Ashdown shared parenting anecdotes and was noted for using humor during the sessions. The participants appreciated that the sessions were “ based around culture and modern medicine” and remarked that “everything in the group was not as medicalized .” All study participants affirmed that the adapted DBT was life-giving. Patient participants described the sessions as “ grounded ” and emphasized that did not feel “ shamed .” They also offered that group discussions and activities helped them to recognize their own resilience. The two providers who co-led the sessions reported several personal and professional insights. The Indigenous Knowledge Carrier observed that “ participants were becoming more aware of their own well-being and not being shamed ” contributing to a holistic and safe environment. This indicated that “ Truth and Reconciliation was being put into action ” which was described as “ hard and heart work. ” The co-leader, a perinatal psychiatrist, noted that partnering traditional wisdom with DBT skills led to positive outcomes for patients in the clinic. Dream The dream phase centered on asking participants more specific questions about what they dreamed or hoped the sessions would achieve in both the short and long term. During the pre-interview, participants were asked to define healthy coping and many shared that it meant “ not snapping ,” “ not losing control ,” and “ being able to take a deep breath before reacting. ” In the post-interview, participants reflected on how the sessions had met their definitions of health coping and all agreed they had increased their ability to meet their definition of healthy coping. During the post-interview one participant commented that “Each day I came out knowing more. I felt empowered, proud, and strengthened.” And another stated “I felt protected and safe. I felt Gramma’s strength..” It was noted that “the [IPMC] clinic is culturally based. And it is inspiring.” and that the “DBT approach was beyond worksheets… was the same skills I was taught before but how it was taught was different..” It was encouraging to hear from one participant that “I know myself more and it encouraged me… I would say I learned more about my culture and who I am.” The participants reported that they could transfer what they learned in the sessions to their everyday life which was noted to be a dream outcome of attending. Examples that supported the use of the DBT skills and cultural teachings included using the STOP (stop, take a step back, observe, Proceed Mindfully) skill and the TIPP (temperature, intense exercise, paced breathing, and progressive muscle relaxation) skill, along with traditional medicines such as cedar to calm oneself when facing stressful decisions or discussions. We also asked about what participants believed the sessions could and could not offer. There was a consensus that the sessions offered peer connections during the group therapies. The post-interviews took place 3-6 weeks following the sessions and although they hoped to maintain the connections it was challenging without set dates and times and funding for transportation. Design Participants and providers were invited to offer detailed feedback on what to keep the same during the sessions and ways to improve the design of the co-led DBT skills and Indigenous cultural teaching sessions. They reached consensus and offered the following logistical suggestions and practice recommendations: Commence with smudging. Start and end with verbal check in and check out. Schedule ninety minute sessions versus 60 minute sessions. Plan for 1200-1330 hour time slot (overlapped with lunch breaks and easy to attend at this time of day). Host sessions in the ceremony room setting in hospital. Noted to be accessible and safe space. Co-led by Psychiatry and an Elder/Knowledge Carrier. Include 6-8 participants per group. 4 sessions (with option to return to another 4 sessions). Provide food (necessary for perinatal patients). Schedule follow-up phone calls for quality assurance and feedback. Offer time for reflection during the follow-up phone calls. Providers added that they need additional administrative support to organize the recruitment, reminders, and logistics. Both co-leaders felt that it was not a responsible use of their time to do the administrative work. Providers agreed that to plan for appropriate staffing in the future there needs to be two Elders/Knowledge Keepers and DBT facilitators available to offer the sessions. Destiny All participants shared that DBT skills and Indigenous cultural teaching sessions should be a sustainable aspect of care for future participants. Participants used the following words to describe their experiences “inspiring, strengthened, hope, stable, fun, crucial, integrative, holistic, helpful, welcoming, and a good time.” Indigenous Knowledge Carrier/Grandmother described the sessions as successful as they were “holistic and embodied the mind, spiritual, emotional and physical person.” Indigenous Knowledge Keeper/Gramma also responded that the program needs to continue as it is a way of “connecting them with their identity and strengthening their already existing strengths.” Providers described the destiny of the program as an “ apprevention ” strategy, referring to the goal of keeping families together as part of a response to the Truth and Reconciliation calls to action [29]. The DBT skills and Indigenous cultural teaching sessions are noted to be “essential to the care paradigm.” and far superior to care wherein a pamphlet is handed out with no follow-up treatment. Having access to a group co-led by Indigenous leadership and psychiatry means that an opportunity is being offered that has the potential to offer lifestyle changes to the patients. Discussion Decolonizing existing health care systems must be action oriented. The results of our study are promising, offering insights into the possibility of a team based model working within existing health care systems to delivery innovative and actionable strategies of care. Our qualitative findings, using appreciative inquiry, illuminate opportunities to integrate simple effective strategies that offer real time impact. Participants in this study outlined the many positive facets of co-led DBT skills and Indigenous cultural teachings for all. Next steps require a program proposal for a sustainable approach to maintain the program beyond a funded research project. Considering this was done by a small research team with a limited budget, we believe that it can be replicated in other sites offering complex care to perinatal persons by an interprofessional care team. Interprofessional perinatal care teams exist globally (Gulbransen et al. 2022) for complex care patients inclusive of those with mental health and substance use disorders. The integration of co-led group sessions with a health care provider and person who can offer cultural teachings is an area that can be expanded in Canada [29]. We recommend utilizing implementation science, focusing on prioritization, leadership, workforce, workflow, and reinforcement, and engaging cultural leaders in these initiatives to fulfill essential roles and make co-led group sessions widely available. Strengths and limitations The qualitative findings provide important context for future research on co-led integrated care approaches. We interviewed both patients and providers thereby offering diverse perspectives. Participants in the pre and post-interviews reported that they appreciated the timing of the post-interview being 3–6 weeks following the sessions as it provided reminders of what they learned. That said, it would be useful to hear from them long term as well to learn about longer term application from the sessions. The few participants who did not participate in the post-interview would have offered further insight into the sessions and may have been in more complex situations following their participation in the sessions. The pre and post-interviews with patient participants were conducted by members of the research team that were not providing care to the patients. This could have enabled interviewees to feel comfortable being open and honest about any challenges or opportunities to improve the sessions. The patient participant interviewers were done over the phone and interviewers introduced themselves as research team members with experience in research and perinatal care, which may have influenced the interviewees comfort level and sharing. The pre and post-interviews with the providers were conducted by the same research team members who had preexisting professional relationships with the providers. The providers were also part of the research team. This could have hindered the openness to sharing and preconceived ideas may have existed. The research team interviewers attempted to counter any such influence by reflective note keeping and discussion of the issue. Recommendations for sustainable services Based on our findings we suggest the following critical aspects to ensure sustainability of on-going DBT sessions: Provide sustainable funding for Elders/Knowledge Carriers to co-lead the sessions. Promote training to onboard more than one psychiatrist, social worker, and Elder. Allocate dedicated administrative support to send reminders to patients, organize food, and book rooms. Dedicate time for the facilitators to update/evolve the resource guide and sessions. Learner involvement in the sessions to foster decolonized approaches in the health care system. Conclusion This study demonstrated the positive impact of an adapted DBT program to include Indigenous cultural teachings. The findings highlighted a very important need to address substance use during the perinatal period in a manner that is holistic and responsive for the IPMC patient population. The DBT and Indigenous cultural teachings, co-led by an Indigenous Knowledge Carrier and a Psychiatrist, were presented through a strengths-based approach. Participants engaged with the teachings across the four sessions, which fostered increased hope, emotional regulation, and resilience. They also developed better coping skills, recognized the importance of their self-identity, and strengthened their positive connection to their culture. The qualitative views of patients and providers on co-led DBT skills and Indigenous cultural teachings sessions have added nuance to innovative care approaches for pregnant individuals with complex psychosocial needs. All patient participants that attended the sessions regardless of ethnicity reported benefits from the co-led sessions. We found that critical components to successful implementation of co-led DBT skills and cultural teaching include facilitation by both a psychiatrist and Indigenous Knowledge Carrier. Abbreviations DBT: dialectical behavior therapy IPMC: Interprofessional Psychosocial Maternity Care Declarations Acknowledgements We acknowledge and are eternally grateful to the patients that participated in this project, they are difference makers in the community. We want to thank Grandmother Shingoose, Indigenous knowledge carrier who has a deep cultural knowledge of traditions, stories, and ceremonies. She is strongly connected to the community, has had a lifelong commitment to learning under the direction of Indigenous Elders, and a commitment to her cultures’ practices. She is a community activist and residential school survivor. And thank you to Dr. Jean Smith who provided editorial review of the manuscript. Funding This research was funded by CIHR, Research Manitoba, Canadian Nurses Foundation, and the Children’s Hospital Foundation Manitoba (Innovator Award). Contributions G.S. and H.A. adapted the DBT and Cultural Teaching Intervention. H.A. and H.W. recruited patients from the IPMC clinic. K.G. connected with recruited patients, organized low barrier access and food for the sessions, sent reminders, and organized pre and post interviews. K.G. and K.T. conducted all the pre and post interviews. K.G. transcribed the interviews supervised by K.T. for accuracy. K.G. wrote the main manuscript as a post doctoral student under the supervision of K.T. All authors reviewed the data, contributed to data analysis, and provided substantial feedback to the manuscript. Both H.A. and G.S. helped select the quotes and provided the edits for the findings section. W.PB. assisted with Table 1. W.PB and G.S. assisted with Table 2. H.W. designed Figure 1. Competing interests There are no competing interests. Ethical Approval The study was approved by Health Research Ethics Board, University of Manitoba (Ethics #: HS26098 (H2023:234). Funding Availability of data and materials Upon request to the corresponding author. References Graves L, Carson G, Poole N, Patel T, Bigalky J, Green CR, et al. Guideline no. 405: Screening and counselling for alcohol consumption during pregnancy. J Obstet Gynaecol Can [Internet]. 2020;42(9):1158-1173.e1. Available from: http://dx.doi.org/10.1016/j.jogc.2020.03.002 Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, et al. Guideline no. 443b: Opioid use throughout women’s lifespan: Opioid use in pregnancy and breastfeeding. J Obstet Gynaecol Can [Internet]. 2023;45(11):102144. Available from: http://dx.doi.org/10.1016/j.jogc.2023.05.012 Schmidt RA, Kaminsky K, Green CR, Cook JL. Current Alcohol Screening and Brief Intervention Practices among Canadian Midwives: Pratiques actuelles des sages-femmes canadiennes en matière de dépistage de l’alcool et d’interventions brèves. Can J Midwifery Res Pract [Internet]. 2024;19(1):33–42. Available from: http://dx.doi.org/10.22374/cjmrp.v19i1.47 Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and postpartum drug overdose deaths in the US before and during the COVID-19 pandemic. JAMA Psychiatry [Internet]. 2024;81(3):270. Available from: http://dx.doi.org/10.1001/jamapsychiatry.2023.4523 Bushnik T, Yang S, Kaufman JS, Kramer MS, Wilkins R. Socioeconomic disparities in small-for-gestational-age birth and preterm birth. Health Rep. 2017;28(11):3–10. Hoang T, Czuzoj-Shulman N, Abenhaim HA. Pregnancy outcome among women with drug dependence: A population-based cohort study of 14 million births. J Gynecol Obstet Hum Reprod [Internet]. 2020;49(7):101741. Available from: http://dx.doi.org/10.1016/j.jogoh.2020.101741 Daoud N, O’Brien K, O’Campo P, Harney S, Harney E, Bebee K, et al. Postpartum depression prevalence and risk factors among Indigenous, non-Indigenous and immigrant women in Canada. Can J Public Health [Internet]. 2019;110(4):440–52. Available from: http://dx.doi.org/10.17269/s41997-019-00182-8 Campbell J, Matoff-Stepp S, Velez ML, Cox HH, Laughon K. Pregnancy-associated deaths from homicide, suicide, and drug overdose: Review of research and the intersection with intimate partner violence. J Womens Health (Larchmt) [Internet]. 2021;30(2):236–44. Available from: http://dx.doi.org/10.1089/jwh.2020.8875 Smylie J, Fell D, Ohlsson A. Joint Working Group on First Nations Indian Inuit; Métis Infant Mortality of the Canadian Perinatal Surveillance System. A review of Aboriginal infant mortality rates in Canada: striking and persistent Aboriginal/non-Aboriginal inequities. Can J Public Health. 2010;101(2):143–8. Grzybowski S, Fahey J, Lai B, Zhang S, Aelicks N, Leung BM, et al. The safety of Canadian rural maternity services: a multi-jurisdictional cohort analysis. BMC Health Serv Res [Internet]. 2015;15(1):410. Available from: http://dx.doi.org/10.1186/s12913-015-1034-6 Koehn K, Cassidy-Matthews C, Pearce M, Aspin C, Pruden H, Ward J, et al. Rates of new HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the United States: 2009-2017: 2009-2017. AIDS [Internet]. 2021;35(10):1683–7. Available from: http://dx.doi.org/10.1097/QAD.0000000000002977 Bacciaglia M, Neufeld HT, Neiterman E, Krishnan A, Johnston S, Wright K. Indigenous maternal health and health services within Canada: a scoping review. BMC Pregnancy Childbirth [Internet]. 2023;23(1):327. Available from: http://dx.doi.org/10.1186/s12884-023-05645-y Wall-Wieler E, Kenny K, Lee J, Thiessen K, Morris M, Roos LL. Prenatal care among mothers involved with child protection services in Manitoba: a retrospective cohort study. CMAJ [Internet]. 2019;191(8):E209–15. Available from: http://dx.doi.org/10.1503/cmaj.181002 Bagley SM, Cabral H, Saia K, Brown A, Lloyd-Travaglini C, Walley AY, et al. Frequency and associated risk factors of non-fatal overdose reported by pregnant women with opioid use disorder. Addict Sci Clin Pract [Internet]. 2018;13(1):26. Available from: http://dx.doi.org/10.1186/s13722-018-0126-0 Thumath M, Humphreys D, Barlow J, Duff P, Braschel M, Bingham B, et al. Overdose among mothers: The association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada. Int J Drug Policy [Internet]. 2021;91(102977):102977. Available from: http://dx.doi.org/10.1016/j.drugpo.2020.102977 Davis EP, Narayan AJ. Pregnancy as a period of risk, adaptation, and resilience for mothers and infants. Dev Psychopathol [Internet]. 2020;32(5):1625–39. Available from: http://dx.doi.org/10.1017/S0954579420001121 Le TL, Kenaszchuk C, Milligan K, Urbanoski K. Levels and predictors of participation in integrated treatment programs for pregnant and parenting women with problematic substance use. BMC Public Health [Internet]. 2019;19(1):154. Available from: http://dx.doi.org/10.1186/s12889-019-6455-4 Rutman D, Hubberstey C, Poole N, Schmidt RA, Van Bibber M. Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming. BMC Pregnancy Childbirth [Internet]. 2020;20(1):441. Available from: http://dx.doi.org/10.1186/s12884-020-03109-1 Goodman DJ, Saunders EC, Wolff KB. In their own words: a qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders. BMC Pregnancy Childbirth [Internet]. 2020;20(1):178. Available from: http://dx.doi.org/10.1186/s12884-020-02872-5 Gulbransen, K. A novel care model: Maternity care experiences of pregnant individuals who use substances. University of Manitoba; 2024. [cited 2024 Oct 20]. Available from: https://mspace.lib.umanitoba.ca/server/api/core/bitstreams/89b4da54-cc15-48e7-bdb5-65789a2ac4b3/content Winnipeg’s history [Internet]. City of Winnipeg. [cited 2024 Oct 20]. Available from: https://www.winnipeg.ca/people-culture/winnipegs-history Guidelines for identification and management of substance use and substance use disorders in pregnancy [Internet]. Who.int. World Health Organization; 2014 [cited 2024 Oct 20]. Available from: https://www.who.int/publications/i/item/9789241548731 Linehan M. DBT? Skills training manual, second edition. New York, NY: Guilford Publications; 2014. Hellberg SN, Bruening AB, Thompson KA, Hopkins TA. Applications of dialectical behavioural therapy in the perinatal period: A scoping review. Clin Psychol Psychother [Internet]. 2023;31(1). Available from: http://dx.doi.org/10.1002/cpp.2937 Four directions teachings.com - aboriginal online teachings and resource centre - © 2006 - 2012 all rights reserved 4D interactive inc., a subsidiary of invert media inc. [cited 2024 Oct 22]; Available from: https://fourdirectionsteachings.com/transcripts/ojibwe.html Roche P, Shimmin C, Hickes S, Khan M, Sherzoi O, Wicklund E, et al. Valuing All Voices: refining a trauma-informed, intersectional and critical reflexive framework for patient engagement in health research using a qualitative descriptive approach. Res Involv Engagem [Internet]. 2020;6(1):42. Available from: http://dx.doi.org/10.1186/s40900-020-00217-2 First Nations Governance Committee [cited 2024 Oct 22]. Available from: https://fnigc.ca/ Smith LT. Decolonizing methodologies: Research and indigenous peoples. London, England: Zed Books; 2021. NCTR - National Centre for Truth and Reconciliation. NCTR; 2020 [cited 2024 Oct 20]. Available from: https://nctr.ca/records/reports/ Marriott R, Strobel NA, Kendall S, Bowen A, Eades A-M, Landes JK, et al. Cultural security in the perinatal period for Indigenous women in urban areas: a scoping review. Women Birth [Internet]. 2019;32(5):412–26. Available from: http://dx.doi.org/10.1016/j.wombi.2019.06.012 Luoma JB, Chwyl C, Kaplan J. Substance use and shame: A systematic and meta-analytic review. Clin Psychol Rev [Internet]. 2019;70:1–12. Available from: http://dx.doi.org/10.1016/j.cpr.2019.03.002 Goodman D, Whalen B, Hodder LC. It’s time to support, rather than punish, pregnant women with substance use disorder. JAMA Netw Open [Internet]. 2019;2(11):e1914135. Available from: http://dx.doi.org/10.1001/jamanetworkopen.2019.14135 LaVallie C, Sasakamoose J. Promoting indigenous cultural responsivity in addiction treatment work: the call for neurodecolonization policy and practice. J Ethn Subst Abuse [Internet]. 2023;22(3):477–99. Available from: http://dx.doi.org/10.1080/15332640.2021.1956392 Chilisa B. Indigenous research methodologies. Thousand Oaks, CA: SAGE Publications; 2011. Mdoe P, Mills TA, Chasweka R, Nsemwa L, Petross C, Laisser R, et al. Lay and healthcare providers’ experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry. BMJ Open [Internet]. 2021;11(9):e046248. Available from: http://dx.doi.org/10.1136/bmjopen-2020-046248 Leeson S, Smith C, Rynne J. Yarning, and appreciative inquiry: The use of culturally appropriate and respectful research methods when working with Aboriginal and Torres Strait Islander women in Australian prisons. Method Innov [Internet]. 2016;9. Available from: http://dx.doi.org/10.1177/2059799116630660 Cooperrider D, Cooperrider D, Srivastva S. The gift of new eyes: Personal reflections after 30 years of appreciative inquiry in organizational life. In: Research in Organizational Change and Development. Emerald Publishing Limited; 2017. p. 81–142. Reed J. Appreciative inquiry: Research for change. Thousand Oaks, CA: SAGE Publications; 2007. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5321173","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370255660,"identity":"b3d3b205-0f37-471c-b091-7d72ac5a6739","order_by":0,"name":"Kristen Gulbransen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYFAC5jYQacAP5fKAEX7ACNEi2QDVwkO0FoMDcGsIaJGPSGx7XFFzx9j42hkzqRs1d2Ts2XsPfmCoscOpxfBGYrvhmWPPzMxu55hJ5xx7xsPDcy5ZguFYMm4tMxLbJBvYDttAtLAd5uGRyDGQYGxgJqDl32Eb49kgLf/AWox/MDbU4/aLBFBLY9thMwNpoJbcNrAWM6Ath3FqMeB52G7Y2HfYWOJ2WrF1bh9Qy5lzaRYJx47jtqU9+djDhm+HDftnJ2+8nfPtsD17e+/hGx9qqnHbcgDO5DBACCfg1AC0pQHOZH+AR90oGAWjYBSMZAAArlhUEkqoNEsAAAAASUVORK5CYII=","orcid":"","institution":"Red Deer College","correspondingAuthor":true,"prefix":"","firstName":"Kristen","middleName":"","lastName":"Gulbransen","suffix":""},{"id":370255664,"identity":"d1b67c2a-8289-49d7-ba27-d1d2c03067fd","order_by":1,"name":"Geraldine Shingoose","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Geraldine","middleName":"","lastName":"Shingoose","suffix":""},{"id":370255665,"identity":"e3e8afba-f116-44c0-ae05-130e50cc3f1f","order_by":2,"name":"Heather Ashdown","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Ashdown","suffix":""},{"id":370255667,"identity":"48b86e7a-617e-4d07-988e-e6144d18b6d5","order_by":3,"name":"Heather Watson","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Watson","suffix":""},{"id":370255669,"identity":"35ceb8cc-efee-4988-959e-353a47892984","order_by":4,"name":"Wanda Phillips-Beck","email":"","orcid":"","institution":"First Nations Health and Social Secretariat of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Wanda","middleName":"","lastName":"Phillips-Beck","suffix":""},{"id":370255671,"identity":"ff470493-8d23-42a9-bbd3-d4c1cd2e26b9","order_by":5,"name":"Kellie Thiessen","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Kellie","middleName":"","lastName":"Thiessen","suffix":""}],"badges":[],"createdAt":"2024-10-23 19:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5321173/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5321173/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69079455,"identity":"12c1bdc5-767a-48f1-9f72-0868d98dd7bd","added_by":"auto","created_at":"2024-11-15 11:41:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":195531,"visible":true,"origin":"","legend":"\u003cp\u003eCo-led Dialectical Behavior Therapy and Indigenous Cultural Teachings\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5321173/v1/46c7b81d1b2196a90ad00418.png"},{"id":70588235,"identity":"b335dfa0-c6d4-4b10-b982-e99fdc1c6bd9","added_by":"auto","created_at":"2024-12-04 16:16:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5321173/v1/5082be2a-563b-4d80-9d1d-b16d30e86952.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-Led Dialectical Behavioral Therapy Skills and Cultural Teachings for Perinatal Persons who are Substance Involved","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInterest in pregnancies affected by substance use has increased significantly over the past five years, driven in part by the mental health and social-welfare crises exacerbated by the COVID-19 pandemic [1, 2, 3, 4]. Much of the emerging literature highlights the severe obstetrical outcomes for parents experiencing psychosocial instability during pregnancy, including preterm birth, fetal growth restriction [5], maternal sepsis, and mortality [6]. These outcomes are often worsened by insufficient prenatal care, stigma, and systemic marginalization, leading to rates of postpartum depression that are more than three times higher in this population [7]. Alarmingly, one in five maternal deaths in Canada is the result of overdose or suicide, and these rates are increasing [8].\u003c/p\u003e\n\u003cp\u003eIn parallel, an emerging body of literature has articulated the disproportionate suffering of pregnant individuals from Indigenous communities in Canada, who face up to four-times the rate of maternal death compared with non-Indigenous counterparts [9]. The enduring impacts of colonization manifest in unattended birth [10], inflated rates of HIV and diabetes [11], and overrepresentation in child apprehension for Indigenous parents [12, 13]. The intersection of risk is multiplicative. For example, one quarter of women/parents with psychosocial comorbidities during pregnancy will develop postpartum depression [7], and one in seven individuals will experience an overdose within one year of birth [14]; if they are also Indigenous, these already high rates double [15].\u003c/p\u003e\n\u003cp\u003eAlthough it can be easy for some to view these individuals as unfortunate statistics, pregnancy is also a time of tremendous transformation, hope, and community connectedness [16]. It has higher rates of substance-use stabilization [17], care-engagement, and the initiation of social support [18] than any other time in adulthood. Pregnant individuals with psychosocial comorbidity also demonstrate resilience, and inventiveness, and are motivated to improve maternity care. Similarly, Indigenous tradition is itself a source of strength. The integration of cultural practices during pregnancy and birth respects and honors the traditions, beliefs, and practices of diverse communities, fostering a sense of trust and comfort [19, 20] . \u0026nbsp;While most of these studies conclude that interprofessional, holistic care strategies are required, operational guidance is lacking and the healthcare system in Canada is heavily colonized. The \u0026nbsp;World Health Organization (WHO) identifies culturally appropriate maternity services as central to their global strategy for enhancing maternal and newborn health and eliminating preventable maternal mortality [21], but there are few examples to draw from to transform care practices to be destigmatized, decolonized, and dignified for these families.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eThe Interprofessional Psychosocial Maternity Care (IPMC) team, located in inner-city Winnipeg, Manitoba, Canada, is a collaborative practice comprising obstetrics, midwifery, psychiatry, nursing, and social work, with opioid agonist therapy (OAT) included within their scope of services. The IPMC is situated in Treaty One Territory, and the many First Nations and Metis in Manitoba share cultural-linguistic heritage with the Anishinaabe (Ojibwe), Ininew (Cree), and Dakota peoples [21]. The IPMC providers deliver care to pregnant individuals with psychosocial comorbidities through clinic visits, virtual appointments, and home or shelter-based visits and support. Their approach aligns with the WHO principles for managing substance use in pregnancy, emphasizing access to prevention and treatment services, respect for autonomy, comprehensive care, and the development and implementation of safeguards against stigma [22]. The IPMC clinician providers, identified as settlers, partnered with local Indigenous scholars and Knowledge Carriers to collaboratively develop the co-led Dialectical Behavior Therapy and Cultural Teachings sessions and research project. Table 1 outlines the research team roles, inclusive of the providers self-location.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Researcher team self-location \u0026amp; team role\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerson\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGramma Shingoose\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eKnowledge Carrier\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003e\u0026nbsp;Aanin, Boozhoo I am Anishinaabe Ikwe from Tootinaowaziibeeng Treaty Reserve, Treaty 4 Territory. My spirit names are Sky Woman, Northern Lights Woman and I come from the Bear Clan. My English name is Geraldine Shingoose. As a Matriarch Grandmother/Great Grandmother, \u0026nbsp;I am strongly connected to the community, continue to work fearlessly on search the landfill, have a lifelong commitment to learning under the direction of Indigenous Elders, and a commitment to my cultures\u0026rsquo; practices. Health care practises have brought harm to Indigenous peoples when they seek health care.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMy participation in Health research has brought me hope in my vision to bring change, and to decolonize health care system. By bringing in Indigenous Strength based practises into Health research and into health care practice. Ekosi.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003eCo Leader Cultural Teaching Facilitator\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeather Ashdown\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePsychiatrist\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003eI have a settler background including primarily British and German origins. I have been significantly advantaged as a white settler in the context of the ongoing genocide against Indigenous people in so-called Canada. I work to dedicate myself in my work and personal life to meaningful and action-based solidarity with Indigenous peoples and also with other BIPOC people who continue to be harmed by systems that uphold white supremacy.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003eCo Leader DBT Facilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeather Watson\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePsychosocial Obstetrics Gynecologist\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003eI am an uninvited settler of primarily Scottish heritage; my family arrived in Canada as orphan \u0026quot;Homestay\u0026quot; children, shipped to southern Ontario to serve the wealthy British families who were established there. I also am descended from those wealthy British lines. My own children have Indigenous heritage which includes the Red River Metis and Blackfoot Cree Nations; I grieve the injustice their ancestors endured at the hands of mine. They have allowed me to companion them as they connect with these legacies as young adults, as I walk my own path towards reconciliation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003eClinical Lead\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003eKristen Gulbransen,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRN PhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003eI am an uninvited settler with Ukrainian, German, and Norwegian background. At the time of this research, I was a postdoctoral student under the supervision of a non-Indigenous Midwife working as a provider and researcher in this clinic committed to working toward Truth and Reconciliation. I am committed to actionable work to decolonize the system and recognize the harms that need to change.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003eResearch Interviewer \u0026amp; Coordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3526%;\"\u003e\n \u003cp\u003eKellie Thiessen, RM RN PhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65.0641%;\"\u003e\n \u003cp\u003eI have a settler background and am a visitor to Treaty 1 Territory in Manitoba. As a white settler I acknowledge that I have unearned privilege in the context of a system that continues to perpetuate harm against Indigenous and BIPOC persons. I am committed to ongoing work in allyship alongside Indigenous communities so healing and reconciliation are the focus of our work together.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5833%;\"\u003e\n \u003cp\u003ePrinciple Investigator,\u0026nbsp;Research Lead\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eKey principles of DBT include mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness [23]. The DBT has been shown to help decrease substance use and overdose rates, \u0026nbsp;suicidal ideation, and depression symptoms [24]. DBT is also beneficial for individuals who have experienced trauma and intimate-partner-violence survivorship, \u0026nbsp;making it particularly valuable for the majority of IPMC patients. The dialectical approach in this therapy integrates the perspectives of the Intelligent Mind and the Emotional Mind in service of a Wise Mind. The principles of balance dovetail nicely with the Anishinaabe teachings of the Four Directions in which spirit, body, heart, and mind seek harmony within the self [25]. The resulting program, adapted for the perinatal population, was co-led by a settler psychiatrist and Indigenous Knowledge Carrier, and provided in a group therapy format. It was called \u0026ldquo;Perinatal Co-Led DBT\u0026rdquo; and participants were invited to attend four one hour sessions (see Figure 1). We aimed to explore the patients\u0026rsquo; experiences of the co-led DBT and Indigenous cultural teaching sessions, its strengths, and their perceptions of the impact of co-led sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eValuing All Voices Framework\u003c/em\u003e guides our on-going work with the population that we serve \u0026nbsp;as it embodies social justice and a health equity lens in qualitative research[26].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThis framework encompasses five key concepts: 1) Education \u0026nbsp;and Communication, 2) Understanding and Acceptance, 3) Trust, 4) Relationship Building, and 5) Self-Awareness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe history of research involving Indigenous peoples in Canada is complex and deeply intertwined with the broader history of colonialism, cultural assimilation, and the struggle for Indigenous rights [27, 28]. This history is marked by periods of exploitation and neglect, and, but in recent years there have been efforts toward reconciliation and collaboration have been made [28]. Our team is advancing the interprofessional care approach and research by adapting DBT in a high-risk perinatal population and responding to the Truth \u0026amp; Reconciliation Calls to Action [29].\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIndigenous engagement process\u003c/h2\u003e \u003cp\u003eWe believe that meaningful engagement with Indigenous individuals is the first step toward a shared journey. Therefore, we aimed to engage Indigenous scholars and Knowledge Carriers in a respectful, honest, and humble way. We also started with the truths that Indigenous pregnant women are more likely to develop clinical complications during pregnancy than non-Indigenous pregnant women are [12] and that this is due to the ongoing harms of colonialism and Indigenous racism [29]. Furthermore, most of our patient population at the IPMC is identified as Indigenous.\u003c/p\u003e \u003cp\u003eThe team aimed to develop a therapeutic intervention that combines Indigenous Ways of Knowing with evidence-based therapy (DBT), prioritizing co-creation with patient input. Integrating cultural practices in maternity care can empower families to connect with their identities during the perinatal period, leading to decreased experience of postpartum depression, and reduced rates of preterm and low birthweight infants.\u003c/p\u003e \u003cp\u003eConventional addiction treatment often views the self as weak, and a source of shame, whereas Indigenous healers value the self as a source of pride with a link to intergenerational strength [30, 31, 32]. Incorporating Indigenous healing practices into medical care has been identified as an essential element of Reconciliation [12, 29, 33] and has been experienced as restorative medicine during pregnancy.\u003c/p\u003e \u003cp\u003eThe IPMC actionable clinic goals recognize the necessity to engage Indigenous Elders, Grandmothers, and Knowledge Carriers in the research process. We recognized Indigenous involvement as essential in conducting respectful, relevant, and impactful research with Indigenous communities. We were aware that researchers must approach this engagement with humility, respect, and a commitment to genuine collaboration. We followed steps of engagement based on Indigenous scholars [28]. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines how our team engaged and partnered with Indigenous Knowledge Carrier as both a research team member lead and a co-facilitator of the co-led DBT and cultural teaching sessions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSteps for Engaging Indigenous Knowledge Carriers in Research\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly and Ongoing Engagement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Initial meeting in Assiniboine park before research study planning. Invitation to Knowledge Carrier to be a research lead and co-facilitator.\u003c/p\u003e \u003cp\u003e\u0026bull; Involved Indigenous researchers from beginning by co-designing the study. DBT skills sessions were adapted to cultural teachings.\u003c/p\u003e \u003cp\u003e\u0026bull; Had a point person on the research team for Indigenous knowledge carrier to connect with regarding protocols and ask any questions.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuilding Relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Frequent communication, open and honest conversations throughout the study.\u003c/p\u003e \u003cp\u003e\u0026bull; Elder/knowledge keeper holds leadership position\u0026nbsp; in all stages of the research study and during the DBT and cultural teaching sessions.\u003c/p\u003e \u003cp\u003e\u0026bull; Participants invited to Assiniboine Park for closing ceremony of the study.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespecting Protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Offered tobacco before study planning commenced. Holding a pipe ceremony to open and close the study.\u003c/p\u003e \u003cp\u003e\u0026bull; Gathered Indigenous sacred medicines for teachings in a respectful way for the sessions and ceremony.\u003c/p\u003e \u003cp\u003e\u0026bull; Advocated for dedicated funding and paying honorarium in a timely way.\u003c/p\u003e \u003cp\u003e\u0026bull; Provided food from local Indigenous restaurant at request of Indigenous Knowledge Carrier.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollaborative Research Design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Respect and honored the Indigenous ways of research (oral teachings offered during sessions, open ended flexible interviews).\u003c/p\u003e \u003cp\u003e\u0026bull; Followed OCAP (ownership, control, access, and possession) principles.\u003c/p\u003e \u003cp\u003e\u0026bull; Incorporated Indigenous oral teachings in the DBT and cultural teaching sessions and research team meetings.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReciprocity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Contributions of Knowledge Carrier highlighted throughout project.\u003c/p\u003e \u003cp\u003e\u0026bull; Met regularly and refine strategies to ensure the sessions remained effective and respectful. Had a giving and receiving relationship.\u003c/p\u003e \u003cp\u003e\u0026bull; Ensured that Indigenous research members had access to necessary resources (transport to sessions, study resources).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge Translation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Promote ways to acknowledge the work Knowledge Carrier Shingoose offered (highlighting in publications, program proposal, discussions with other providers).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAppreciative inquiry\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe employed Appreciative Inquiry as a qualitative research method, conducting interviews with both participants and providers. Appreciative inquiry is a strength-based approach that focuses on strengths and opportunities for improving care [32]. When utilized as a research method, appreciative inquiry is a generative process focused on positive ways to explore, discover, and transform systems\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[34]. Identifying strengths can yield actionable ways to promote best practices in health care systems [32]. Our aim was to use a research approach that would limit unintentional retraumatization while highlighting the strengths within the patients and the existing system. Embedded in critical social theory, appreciative inquiry supports an open dialogue wherein people at the point of care are encouraged to engage in practice development to improve their setting and experiences [35].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Manitoba Health Research Ethics Board and the Shared Health Ethics Committee. All participants provided written or verbal consent. The decision to use appreciative inquiry as a method was well supported by the research team and ethics review boards. Engaging patient participants was essential to ensure that priorities from the patient perspective were at the forefront. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy context: Co-led DBT skills and Indigenous cultural teachings\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe adapted and implemented Dialectical Behavior Therapy (DBT) skills sessions for pregnant individuals with psychosocial comorbidities, on the basis of Dr. Marsha Linehan\u0026rsquo;s DBT Skills manual [23]. Our adaptation incorporated cultural teachings delivered by an Indigenous knowledge carrier/Grandmother team member. The DBT sessions were co-led by an Indigenous Knowledge Carrier/Grandmother and a psychiatrist. Knowledge Carrier/Grandmother Shingoose was the Indigenous knowledge carrier with a deep cultural knowledge of traditions, stories and ceremonies and Dr Ashdown focused on perinatal mental health. Table 3 provides an overview of the session topics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Co-Led DBT skills and Indigenous Cultural Teaching Overview\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndigenous Cultural Teachings\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDBT skills teaching\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWeek 1: Spiritual Health\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCedar teachings\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMindfulness DBT Skills\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWeek 2: Emotional Health\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSage teachings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmotion Regulation DBT Skills\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWeek 3: Mental Health\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTobacco teachings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmotion Regulation and Interpersonal DBT Skills\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWeek 4: Physical Health\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSweetgrass teachings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistress Tolerance DBT Skills\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOur approach to care is grounded in the belief that integrated care is inherently more holistic and that prioritizing spiritual wellbeing is not in conflict with medical care priorities. Our adaptation to DBT includes the following rationale: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eIncorporation of Indigenous medicine is grounded in the self as a source of strength and pride. In contrast, addiction treatment is often grounded in self as a source of weakness and shame.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCo-led integrated care is inherently more holistic .\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePrioritizing spiritual wellbeing and cultural teachings is not in conflict with medical care priorities.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDBT being adapted to the perinatal period and partnered with Indigenous specific curricula from the Knowledge Carrier/Grandmother on our team is responsive to the TRC work.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDuring the perinatal period more than any one time in the life course, pregnancy is a catalyst for change. Who we are as individuals, in our communities, as sacred water carriers all collide in pregnancy.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDBT leverages willingness in pursuit of a more sustainable way to cope with life\u0026apos;s challenges.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eSampling\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe worked collaboratively to establish inclusion and exclusion criteria prior to recruitment. The inclusion criteria were as follows: patients who have their own agency and decision-making power over their health care and are antepartum or up to 12 weeks postpartum at the time of patient invitation. We did not engage minors, nor did we engage patients who were psychologically or physically unstable. We prioritized a representative group of patients which included Black, Indigenous, and People of Color (BIPOC), and represented the IPMC clinic population. The team \u0026nbsp;of clinicians screened patients prior to any initiation of engagement with these inclusion criteria as their guide. The obstetrician and psychiatrist who provided care at the clinic contacted patients at the end of their routine appointments to invite them to participate in the co-led DBT skills and Indigenous cultural teaching sessions. They obtained consent to contact for the research interviewers (KT, KG) who then obtained informed consent. Participation in the study was not a requirement for attending the co-led DBT and cultural teaching sessions. All potential participants were given a copy of the research consent form to review prior to the interviews, and a Pledge of Confidentiality was signed before participation.\u003c/p\u003e\n\u003cp\u003eThe IPMC providers invited 12 patients to participate in the DBT skills and Indigenous teaching sessions. Three participants chose to defer participation during the spring sessions, while nine participants signed up for the sessions and completed the pre-interview. Out of those, seven participants completed the post-interview. The two participants who did not complete the post-interview did not attend any of the sessions and opted to defer their participation in the DBT and cultural teaching sessions until a later date. Additionally, three individual interviews were conducted with the IPMC providers and the Indigenous knowledge carrier.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSemi-structured interview guides were designed for pre interviews conducted 1-2 weeks before the DBT and cultural teaching sessions. Post-interviews occurred 3-6 weeks after the sessions with participants. Input on the interview guide was sought from an Indigenous scholar, Indigenous Knowledge Carrier, and appreciative inquiry expert. This collaboration aimed to keep the questions strength based and relevant to the study aim.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach interview followed the 4D model of appreciative inquiry; Discovery, Dream, Design and Destiny [36, 37]. In the Discovery phase, the focus was on soliciting participants\u0026apos; perspectives on the DBT and cultural teaching sessions. The Dream phase invited participants to share their visions for improved care experiences during these sessions. In the Design phase, participants were encouraged to provide actionable ideas on how providers and the healthcare system could support and sustain the ideal care experience. Finally, the Destiny phase explored realistic strategies for enacting and sustaining the DBT and cultural teaching sessions.\u003c/p\u003e\n\u003cp\u003eQuestions were designed to elicit participants\u0026rsquo; views on what they hoped to achieve from the sessions, what aspects they found most valuable and practical for their daily lives, and suggestions for program improvement. The semi-structured interviews were conducted by two researchers (KT, KG) with participants via telephone and with the IPMC providers via video meetings. Data were audio recorded and transcribed verbatim. The transcripts were checked for accuracy by the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAnalysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData were analyzed following appreciative inquiry which focuses on making sense of the data through the lens of participants\u0026rsquo; experiences and perspectives [37, 38]. We adopted the appreciative inquiry approach because it can facilitate positive change in systems by identifying existing strengths and opportunities for future improvement. Research team members convened from May 2024 to July 2024 to analyze the data. We read the transcripts in their entirety multiple times to gain an overall understanding and identify keywords or phrases that would form codes, themes, and subthemes [38]. A reflexive stance was adopted, with researchers demonstrating self-awareness by acknowledging their positionality and examining their own thoughts, feelings, and actions throughout the research process [38].\u003c/p\u003e\n\u003cp\u003eExamining the context of the co-led DBT and cultural teaching sessions aided us in identifying and exploring what is important to participants and what made participating possible. Patterns and consensus on the strengths and logistics of the sessions were identified during review of the data. In this article, we present quotes without any participant identifiers or use of pseudonyms from all seven participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe IPMC providers invited 12 patients to participate in the DBT skills and Indigenous teaching sessions. Nine participants signed up for the sessions and completed the pre-interview, and seven participants completed the post-interview while 3 deferred to attend sessions outside of the study timeframe. All patient participants met inclusion criteria for the study and represented both prenatal (n=5) and postpartum (n=4) patients, Indigenous (n=7) and non-Indigenous (n=2). Additionally, three individual interviews were completed with the IPMC providers (obstetrician, psychiatrist, and Indigenous Knowledge Carrier).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study revealed a number of outcomes for the patient participants related to attending the co-led DBT and Indigenous Cultural Teaching sessions. These were shared throughout all stages of the 4 D\u0026rsquo;s and themed as follows: hope, increased emotional regulation and resilience, increased coping, recognition of the importance of their own self-identity, and positive cultural connection. There were also unintended outcomes for the providers. They described the sessions as significantly increasing their job satisfaction, as the antidote to burnout, and as actionably responsive to Truth and Reconciliation [29]. We followed the 4Ds of Appreciative Inquiry to present the data/participants\u0026rsquo; quotes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiscovery\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe responses during the pre-interview with participants revealed that hope was at the forefront of the sessions. The participants expressed optimism that the sessions would provide teachings on emotional regulation, coping techniques, spiritual health, and self-identity in the pre-interview. The participant responses from the discovery phase during the post interview confirmed that the sessions met their expectations related to emotional regulation, coping techniques, and self-identity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants \u0026nbsp;described the best parts of the DBT and Indigenous teaching sessions as \u0026nbsp;\u003cem\u003e\u0026ldquo;I have more coping skills\u0026hellip; because of both of their teachings\u0026rdquo;\u0026nbsp;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;reminded spirituality is embedded in all that I do.\u0026rdquo;\u003c/em\u003e Participants provided further comments that the most valuable aspects of the co-led DBT and Indigenous teaching sessions with comments such as, \u0026ldquo;\u003cem\u003eI was reminded that spirituality is embedded in all that I do.\u003c/em\u003e\u0026rdquo; They emphasized the significance of having co-led sessions, noting that \u0026ldquo;\u003cem\u003eseeing and having Dr. Ashdown and Gramma work together, and having it all planned out together\u003c/em\u003e\u0026rdquo; was one of the highlights that \u0026ldquo;\u003cem\u003emade a difference.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStorytelling by the co-leaders was particularly well-received. Gramma Shingoose shared stories of resilience, grit, parenting, surviving residential school, and cultural teachings. The perinatal psychiatrist, Dr Ashdown shared parenting anecdotes and was noted for using humor during the sessions. The participants appreciated that the sessions were \u0026ldquo;\u003cem\u003ebased around culture and modern medicine\u0026rdquo; and remarked that \u0026ldquo;everything in the group was not as medicalized\u003c/em\u003e.\u0026rdquo; All study participants affirmed that the adapted DBT was life-giving. Patient participants described the sessions as \u0026ldquo;\u003cem\u003egrounded\u003c/em\u003e\u0026rdquo; and emphasized that did not feel \u0026ldquo;\u003cem\u003eshamed\u003c/em\u003e.\u0026rdquo; They also offered that group discussions and activities helped them to recognize their own resilience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe two providers who co-led the sessions reported several personal and professional insights. The Indigenous Knowledge Carrier observed that \u0026ldquo;\u003cem\u003eparticipants were becoming more aware of their own well-being and not being shamed\u003c/em\u003e\u0026rdquo; contributing to a holistic and safe environment. This indicated that \u0026ldquo;\u003cem\u003eTruth and Reconciliation was being put into action\u003c/em\u003e\u0026rdquo; which was described as \u0026ldquo;\u003cem\u003ehard and heart work.\u003c/em\u003e\u0026rdquo; The co-leader, a perinatal psychiatrist, noted that partnering traditional wisdom with DBT skills led to positive outcomes for patients in the clinic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDream\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe dream phase centered on asking participants more specific questions about what they dreamed or hoped the sessions would achieve in both the short and long term. During the pre-interview, participants were asked to define healthy coping and many shared that it meant \u0026ldquo;\u003cem\u003enot snapping\u003c/em\u003e,\u0026rdquo; \u0026ldquo;\u003cem\u003enot losing control\u003c/em\u003e,\u0026rdquo; and \u0026ldquo;\u003cem\u003ebeing able to take a deep breath before reacting.\u003c/em\u003e\u0026rdquo; In the post-interview, participants reflected on how the sessions had met their definitions of health coping and all agreed they had increased their ability to meet their definition of healthy coping.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the post-interview one participant commented that \u003cem\u003e\u0026ldquo;Each day I came out knowing more. I felt empowered, proud, and strengthened.\u0026rdquo;\u0026nbsp;\u003c/em\u003eAnd another stated \u003cem\u003e\u0026ldquo;I felt protected and safe. I felt Gramma\u0026rsquo;s strength..\u0026rdquo;\u003c/em\u003e It was noted that \u003cem\u003e\u0026ldquo;the [IPMC] clinic is culturally based. And it is inspiring.\u0026rdquo;\u0026nbsp;\u003c/em\u003eand that the \u003cem\u003e\u0026ldquo;DBT approach was beyond worksheets\u0026hellip; was the same skills I was taught before but how it was taught was different..\u0026rdquo;\u003c/em\u003e It was encouraging to hear from one participant that \u003cem\u003e\u0026ldquo;I know myself more and it encouraged me\u0026hellip; I would say I learned more about my culture and who I am.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe participants reported that they could transfer what they learned in the sessions to their everyday life which was noted to be a dream outcome of attending. Examples that supported the use of the DBT skills and cultural teachings included using the STOP (stop, take a step back, observe, Proceed Mindfully) skill and the TIPP (temperature, intense exercise, paced breathing, and progressive muscle relaxation) skill, along with traditional medicines such as cedar to calm oneself when facing stressful decisions or discussions.\u003c/p\u003e\n\u003cp\u003eWe also asked about what participants believed the sessions could and could not offer. There was a consensus that the sessions offered peer connections during the group therapies. The post-interviews took place 3-6 weeks following the sessions and although they hoped to maintain the connections it was challenging without set dates and times and funding for transportation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDesign\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants and providers were invited to offer detailed feedback on what to keep the same during the sessions and ways to improve the design of the co-led DBT skills and Indigenous cultural teaching sessions. They reached consensus and offered the following logistical suggestions and practice recommendations: \u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eCommence with smudging.\u003c/li\u003e\n \u003cli\u003eStart and end with verbal check in and check out.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchedule ninety minute sessions versus 60 minute sessions.\u003c/li\u003e\n \u003cli\u003ePlan for 1200-1330 hour time slot \u0026nbsp;(overlapped with lunch breaks and easy to attend at this time of day).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHost sessions in the ceremony room setting in hospital. Noted to be accessible and safe space.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCo-led by Psychiatry and an Elder/Knowledge Carrier.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eInclude 6-8 participants per group.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e4 sessions (with option to return to another 4 sessions).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvide food (necessary for perinatal patients).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchedule follow-up phone calls for quality assurance and feedback. Offer time for reflection during the follow-up phone calls.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eProviders added that they need additional administrative support to organize the recruitment, reminders, and logistics. Both co-leaders felt that it was not a responsible use of their time to do the administrative work. Providers agreed that to plan for appropriate staffing in the future \u0026nbsp;there needs to be two Elders/Knowledge Keepers and DBT facilitators available to offer the sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDestiny\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants shared that DBT skills and Indigenous cultural teaching sessions should be a sustainable aspect of care for future participants. Participants used the following words to describe their experiences \u003cem\u003e\u0026ldquo;inspiring, strengthened, hope, stable, fun, crucial, integrative, holistic, helpful, welcoming, and a good time.\u0026rdquo;\u003c/em\u003e Indigenous Knowledge Carrier/Grandmother described the sessions as successful as they were \u003cem\u003e\u0026ldquo;holistic and embodied the mind, spiritual, emotional and physical person.\u0026rdquo;\u003c/em\u003e Indigenous Knowledge Keeper/Gramma also responded that the program needs to continue as it is a way of \u003cem\u003e\u0026ldquo;connecting them with their identity and strengthening their already existing strengths.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProviders described the destiny of the program as an \u003cu\u003e\u0026ldquo;\u003c/u\u003e\u003cem\u003eapprevention\u003c/em\u003e\u003cu\u003e\u0026rdquo;\u003c/u\u003e strategy, referring to the goal of keeping families together as part of a response to the Truth and Reconciliation calls to action [29]. The DBT skills and Indigenous cultural teaching sessions are noted to be \u003cem\u003e\u0026ldquo;essential to the care paradigm.\u0026rdquo;\u0026nbsp;\u003c/em\u003eand far superior to care wherein a pamphlet is handed out with no follow-up treatment. Having access to a group co-led by Indigenous leadership and psychiatry means that an opportunity is being offered that has the potential to offer lifestyle changes to the patients.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDecolonizing existing health care systems must be action oriented. The results of our study are promising, offering insights into the possibility of a team based model working within existing health care systems to delivery innovative and actionable strategies of care. Our qualitative findings, using appreciative inquiry, illuminate opportunities to integrate simple effective strategies that offer real time impact. Participants in this study outlined the many positive facets of co-led DBT skills and Indigenous cultural teachings for all.\u003c/p\u003e \u003cp\u003eNext steps require a program proposal for a sustainable approach to maintain the program beyond a funded research project. Considering this was done by a small research team with a limited budget, we believe that it can be replicated in other sites offering complex care to perinatal persons by an interprofessional care team. Interprofessional perinatal care teams exist globally (Gulbransen et al. 2022) for complex care patients inclusive of those with mental health and substance use disorders.\u003c/p\u003e \u003cp\u003eThe integration of co-led group sessions with a health care provider and person who can offer cultural teachings is an area that can be expanded in Canada [29]. We recommend utilizing implementation science, focusing on prioritization, leadership, workforce, workflow, and reinforcement, and engaging cultural leaders in these initiatives to fulfill essential roles and make co-led group sessions widely available.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe qualitative findings provide important context for future research on co-led integrated care approaches. We interviewed both patients and providers thereby offering diverse perspectives. Participants in the pre and post-interviews reported that they appreciated the timing of the post-interview being 3\u0026ndash;6 weeks following the sessions as it provided reminders of what they learned. That said, it would be useful to hear from them long term as well to learn about longer term application from the sessions.\u003c/p\u003e \u003cp\u003e The few participants who did not participate in the post-interview would have offered further insight into the sessions and may have been in more complex situations following their participation in the sessions. The pre and post-interviews with patient participants were conducted by members of the research team that were not providing care to the patients. This could have enabled interviewees to feel comfortable being open and honest about any challenges or opportunities to improve the sessions. The patient participant interviewers were done over the phone and interviewers introduced themselves as research team members with experience in research and perinatal care, which may have influenced the interviewees comfort level and sharing.\u003c/p\u003e \u003cp\u003eThe pre and post-interviews with the providers were conducted by the same research team members who had preexisting professional relationships with the providers. The providers were also part of the research team. This could have hindered the openness to sharing and preconceived ideas may have existed. The research team interviewers attempted to counter any such influence by reflective note keeping and discussion of the issue.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for sustainable services\u003c/h2\u003e \u003cp\u003eBased on our findings we suggest the following critical aspects to ensure sustainability of on-going DBT sessions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eProvide sustainable funding for Elders/Knowledge Carriers to co-lead the sessions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePromote training to onboard more than one psychiatrist, social worker, and Elder.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAllocate dedicated administrative support to send reminders to patients, organize food, and book rooms.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDedicate time for the facilitators to update/evolve the resource guide and sessions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLearner involvement in the sessions to foster decolonized approaches in the health care system.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated the positive impact of an adapted DBT program to include Indigenous cultural teachings. The findings highlighted a very important need to address substance use during the perinatal period in a manner that is holistic and responsive for the IPMC patient population. The DBT and Indigenous cultural teachings, co-led by an Indigenous Knowledge Carrier and a Psychiatrist, were presented through a strengths-based approach. Participants engaged with the teachings across the four sessions, which fostered increased hope, emotional regulation, and resilience. They also developed better coping skills, recognized the importance of their self-identity, and strengthened their positive connection to their culture.\u003c/p\u003e \u003cp\u003eThe qualitative views of patients and providers on co-led DBT skills and Indigenous cultural teachings sessions have added nuance to innovative care approaches for pregnant individuals with complex psychosocial needs. All patient participants that attended the sessions regardless of ethnicity reported benefits from the co-led sessions. We found that critical components to successful implementation of co-led DBT skills and cultural teaching include facilitation by both a psychiatrist and Indigenous Knowledge Carrier.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDBT: dialectical behavior therapy\u003c/p\u003e\n\u003cp\u003eIPMC: Interprofessional Psychosocial Maternity Care\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge and are eternally grateful to the patients that participated in this project, they are difference makers in the community. We want to thank Grandmother Shingoose, Indigenous knowledge carrier who has a deep cultural knowledge of traditions, stories, and ceremonies. She is strongly connected to the community, has had a lifelong commitment to learning under the direction of Indigenous Elders, and a commitment to her cultures\u0026rsquo; practices. She is a community activist and residential school survivor. And thank you to Dr. Jean Smith who provided editorial review of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by CIHR, Research Manitoba, Canadian Nurses Foundation, and the Children\u0026rsquo;s Hospital Foundation Manitoba (Innovator Award).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eG.S. and H.A. adapted the DBT and Cultural Teaching Intervention. H.A. and H.W. recruited patients from the IPMC clinic. K.G. connected with recruited patients, organized low barrier access and food for the sessions, sent reminders, and organized pre and post interviews. K.G. and K.T. conducted all the pre and post interviews. K.G. transcribed the interviews supervised by K.T. for accuracy. K.G. wrote the main manuscript as a post doctoral student under the supervision of K.T. All authors reviewed the data, contributed to data analysis, and provided substantial feedback to the manuscript. Both H.A. and G.S. helped select the quotes and provided the edits for the findings section. W.PB. assisted with Table 1. W.PB and G.S. assisted with Table 2. H.W. designed Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by Health Research Ethics Board, University of Manitoba (Ethics #: HS26098 (H2023:234).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUpon request to the corresponding author.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGraves L, Carson G, Poole N, Patel T, Bigalky J, Green CR, et al. Guideline no. 405: Screening and counselling for alcohol consumption during pregnancy. J Obstet Gynaecol Can [Internet]. 2020;42(9):1158-1173.e1. 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Available from: http://dx.doi.org/10.1016/j.wombi.2019.06.012\u003c/li\u003e\n\u003cli\u003eLuoma JB, Chwyl C, Kaplan J. Substance use and shame: A systematic and meta-analytic review. Clin Psychol Rev [Internet]. 2019;70:1\u0026ndash;12. Available from: http://dx.doi.org/10.1016/j.cpr.2019.03.002\u003c/li\u003e\n\u003cli\u003eGoodman D, Whalen B, Hodder LC. It\u0026rsquo;s time to support, rather than punish, pregnant women with substance use disorder. JAMA Netw Open [Internet]. 2019;2(11):e1914135. Available from: http://dx.doi.org/10.1001/jamanetworkopen.2019.14135\u003c/li\u003e\n\u003cli\u003eLaVallie C, Sasakamoose J. Promoting indigenous cultural responsivity in addiction treatment work: the call for neurodecolonization policy and practice. J Ethn Subst Abuse [Internet]. 2023;22(3):477\u0026ndash;99. Available from: http://dx.doi.org/10.1080/15332640.2021.1956392\u003c/li\u003e\n\u003cli\u003eChilisa B. Indigenous research methodologies. Thousand Oaks, CA: SAGE Publications; 2011.\u003c/li\u003e\n\u003cli\u003eMdoe P, Mills TA, Chasweka R, Nsemwa L, Petross C, Laisser R, et al. Lay and healthcare providers\u0026rsquo; experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry. BMJ Open [Internet]. 2021;11(9):e046248. Available from: http://dx.doi.org/10.1136/bmjopen-2020-046248\u003c/li\u003e\n\u003cli\u003eLeeson S, Smith C, Rynne J. Yarning, and appreciative inquiry: The use of culturally appropriate and respectful research methods when working with Aboriginal and Torres Strait Islander women in Australian prisons. Method Innov [Internet]. 2016;9. Available from: http://dx.doi.org/10.1177/2059799116630660\u003c/li\u003e\n\u003cli\u003eCooperrider D, Cooperrider D, Srivastva S. The gift of new eyes: Personal reflections after 30 years of appreciative inquiry in organizational life. In: Research in Organizational Change and Development. Emerald Publishing Limited; 2017. p. 81\u0026ndash;142.\u003c/li\u003e\n\u003cli\u003eReed J. Appreciative inquiry: Research for change. Thousand Oaks, CA: SAGE Publications; 2007.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"substance use, perinatal, dialectical behavior therapy, cultural teachings","lastPublishedDoi":"10.21203/rs.3.rs-5321173/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5321173/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study explored perinatal patient experiences in a co-led Dialectical Behavior Therapy (DBT) and Indigenous cultural teachings program. The aim was to understand the programs strengths, impact, and areas for improvement.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Guided by the Valuing All Voices Framework and using Appreciative Inquiry, interviews were conducted with participants (n\u0026thinsp;=\u0026thinsp;9) and providers (n\u0026thinsp;=\u0026thinsp;3) to capture their perspectives on participating and facilitating in the co-led session.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe DBT and Indigenous cultural teachings, co-led by an Indigenous Knowledge Carrier and a Psychiatrist, were presented through a strengths-based approach. Participants engaged with the teachings across the four sessions, which fostered increased hope, emotional regulation, and resilience. They also developed better coping skills, recognized the importance of their self-identity, and strengthened their positive connection to their culture.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study illustrates a promising DBT and cultural teaching approach for integrating culturally appropriate teachings within perinatal mental health care, responding to calls for Truth and Reconciliation, and addressing health disparities.\u003c/p\u003e","manuscriptTitle":"Co-Led Dialectical Behavioral Therapy Skills and Cultural Teachings for Perinatal Persons who are Substance Involved","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:40:58","doi":"10.21203/rs.3.rs-5321173/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73ccd4ce-7a83-4108-923e-38159d2dc9d6","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-04T16:08:48+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:40:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5321173","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5321173","identity":"rs-5321173","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}