Pathways of recovery: preventing further episodes of mental illness (monograph)

Aboriginal peoples and Torres Strait Islanders

Page last updated: 2006

There are special challenges with regard to all the aspects of relapse prevention identified in this monograph for Aboriginal peoples and Torres Strait Islanders3. Fundamentally, this issue must be considered within the broader context that the emotional and social wellbeing of Aboriginal peoples and Torres Strait Islanders is a significant health concern for Australia and a source of national shame. Culturally appropriate mental health care is not widely available in most jurisdictions and the provision of basic health and community services is an urgent and basic need for Aboriginal communities. It must be noted that Aboriginal peoples and Torres Strait Islanders comprise diverse groups of peoples who live in a variety of urban, rural and remote, traditional and other settings (Swan & Raphael 1995). It is, therefore, overly simplistic to make statements that apply to all Aboriginal peoples and Torres Strait Islanders. Furthermore, the issues described in many other sections of this paper, especially for rural and remote communities and issues related to socio-economic disadvantage, also apply.

A recent major initiative addressing mental health is the National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and Emotional Wellbeing 2004-2009. This document presents the specific challenges for mental health care for Aboriginal peoples and Torres Strait Islanders. Holistic health care is prioritised, recognising the integrally interrelated states of physical health, sexual and gender identity, family relationships, education, employment, community relationships and spirituality for Aboriginal and Torres Strait Islander communities and peoples.

In terms of awareness of mental health status, the Ways Forward report reflected on the holistic nature of health and mental health within an Aboriginal context (Swan & Raphael 1995). The construction of mental illness is a cultural concept developed mostly within a western context and it is a frustrating reality that many of the assessment tools used by clinicians have little or no cross-cultural validity. Consequently, the expression of early warning signs and symptoms of recurrent mental illness for Aboriginal peoples and Torres Strait Islanders is unexplored. Furthermore, construction of the sense of self for Aboriginal peoples and Torres Strait Islanders is complex and incorporates the family and extended clan group, alongside an elaborate set of relational bonds and reciprocal obligations. It may also incorporate a profound sense of continuity through Aboriginal Law and Dreaming. It is unknown how awareness and acceptance of having a mental illness, and of thereby being at increased risk of recurrent symptoms, translates within an Aboriginal or Torres Strait Islander context. A first step for preventing relapse for people from Aboriginal or Torres Strait Islander backgrounds is understanding the narrative of their personal construction of self and of their symptoms of mental illness.

Stigma toward people with mental illness is evident within Aboriginal and Torres Strait Islander communities. This can be inadvertently perpetuated by health care providers who cannot speak the Aboriginal language and use short-hand forms of verbal and non-verbal communication.

We really need to stop using the term 'rama rama' to refer to people with mental illness when we come out to the communities. It really means something like crazy and we wouldn't use such terms when referring to people in town, would we? But we allow short-cuts like this out in the bush, because we don't have ways to communicate these things better. —Remote health worker Top of page
Anticipating potential relapse and planning for such an event entails working within existing relational bonds and community supports. It is likely that the less individualistic nature of Aboriginal and Torres Strait Islander communities is a major strength upon which to draw. People from an Aboriginal or Torres Strait Islander community who have experienced a mental illness may still be well integrated within that community and able to draw upon its supports. Planning for relapse prevention needs to be flexible and work through a wellbeing focus, rather than a specific illness or crisis focus. Nevertheless, it is important that Aboriginal peoples and Torres Strait Islanders be given opportunities to express their preferences should a crisis arise and that these choices are respected and upheld.

Aboriginal families can be more accepting of illness. There are more extended networks. For example, there is not so much concern where children go because of all the family networks. —Aboriginal health representative
Hospital care can be a particularly inappropriate response for Aboriginal peoples and Torres Strait Islanders experiencing mental illness, especially for those who live in remote communities and in a more traditional lifestyle. A study of Aboriginal peoples in Central Australia reported that 90% wanted alternatives to hospital care, compared with 47% of non- Aboriginal people (O'Kane, Briscoe & Fowler 1999). Similar results were found for the Top End (Nagel, Mills & Adams 1996). Being taken out of their community and placed in a city hospital as the result of a mental health crisis is a significant added trauma.

Timely access to mental health services of any type is, however, a major problem for many rural and remote Aboriginal and Torres Strait Islander communities. Treatment and support services are often not available to enable any attempt at early intervention for recurrent mental health problems. Until issues around basic levels of service provision are addressed it will be difficult to implement relapse prevention in these communities.

We are so backward in treatment because we don't have the same resources. A lot of the consumers I work with talk about just getting treatment, medication treatment, any treatment. There is no psychotherapy. And we've been pushing for a long time to get more information about other therapy. We've got such diverse populations and basically it's all medication orientated. —Consumer/carer advocate
Fundamentally, there is an urgent need for a more culturally appropriate response from mainstream mental health and health providers. It has been estimated that only 10% of non- Aboriginal practitioners feel confident working with Aboriginal mental health (Westerman 2002). Based on a model developed by Cross and Bazron (1989) and adapted to the Aboriginal Australian context, Westerman defines cultural competence as ranging between: aversion, incompetence, blindness, precompetence, competence and proficiency. There are very few mental health workers who are able to attain levels of cultural competence or proficiency. The experience of many Aboriginal communities is that the majority of mental health professionals will fall into the cultural precompetence level, defined by Cross and Bazron as including those who are aware of their own personal limitations regarding cross-cultural communication. While the intention to provide a quality service exists, the workforce is often frustrated by a lack of knowledge as to the most appropriate manner to deliver services, and is often unaware of their lack of understandings and limitations.

It is also the case that there is high turnover of health care providers within Aboriginal and Torres Strait Islander communities, particularly those that are rural and remote. This means that cultural competence does not have time to develop and communities are continually exposed to new workers who are not able to develop the necessary skills or confidence. High turnover of service providers also means that linkages and partnerships between service providers do not have the opportunity to develop and consolidate, yet these linkages are essential to relapse prevention.
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It is also the case that there is high turnover of health care providers within Aboriginal and Torres Strait Islander communities, particularly those that are rural and remote. This means that cultural competence does not have time to develop and communities are continually exposed to new workers who are not able to develop the necessary skills or confidence. High turnover of service providers also means that linkages and partnerships between service providers do not have the opportunity to develop and consolidate, yet these linkages are essential to relapse prevention.

Mental health care is carried out in many communities by the families, local clinic, Aboriginal health workers and community supports (Sheldon Remote Mental Health Team 2003). Ongoing mental health care requires acknowledgement and respect for the interconnectedness of kinship, culture, law, land and spirituality, as well as the effects of invasion, colonisation and ongoing cultural stress. Cultural consultants or Aboriginal mental health workers act as guides to the culture and ensure that health interventions are carried out in culturally appropriate ways. The Ways Forward report recommended that there be a minimum of two Aboriginal mental health workers, a male and a female, in each region, but this target has not been achieved. Aboriginal mental health workers are essential for relapse prevention, as they have extensive knowledge of the client's family and circumstances, the community, supports and traditional practices, and are able to connect people with the types of supports they require. Furthermore, the role of Aboriginal mental health worker provides an opportunity for community people to have a real job in their community and these types of opportunities are essential for the wellbeing of communities.

The job of Aboriginal health worker is a real job in the community that people can aspire to. They can get training and better money. They think, 'We want that job', because it has a bit of status and is better than sitting around on CDP and getting paid to do nothing. —Community mental health worker
There are some quite specific mental health interventions that could be better developed for people of Aboriginal and Torres Strait Islander backgrounds. For example, it has been suggested that a more narrative therapy approach is required; this approach enables people to tell their stories which may improve communication with Aboriginal clients and enable better understanding of the richness and complexity of their lived experiences (Wingard & Lester 2001). There is also need to explore the cultural translation of therapies that have been shown to be efficacious for preventing relapse in western settings; for example, cognitive behaviour therapies.

We call it Bush CBT. We use it a lot in bush work. It is our way of doing CBT work with people in the communities. I don't think you'll read about it anywhere, it probably hasn't been documented anywhere. That would be a really useful thing – to have some resources to do BCBT – it would be a really useful project for someone to properly develop those. —Aboriginal health worker
It is important in some communities to be able to incorporate traditional healing practices in order to provide a culturally appropriate approach to relapse prevention. For example, many Aboriginal people in Central Australia would consult a traditional healer or Ngangkari in the first instance, and these people may provide an opportunity for early intervention.

A Ngangkari is a very clever person – they know all about sickness – they can look inside and see their sickness. They can look and see that someone is unhappy or mad or something is wrong with their head, from looking at their face ... and they will touch his head and hold it tightly, and pull something out of his head, it might be a stone or a stick, or a mamu (bad spirit) inside making him crazy. Then at night when the Ngangkari is asleep, his spirit might go to that young fella's place and go inside his head and fight with that mamu and pull it out and get rid of it. That young fella will wake up and think, "Oh I'm happy, I'm feeling good, my head is no longer heavy – that mamu is going". (Thomas 2000 p5 cited in Sheldon Remote Mental Health Team 2003)
Cultural stress, grief and trauma have unique impacts on the mental health of Aboriginal peoples. A manifestation of these issues is increased risk of suicide and self-harm (Swan & Raphael 1995). It is, therefore, essential that mental health services work in partnership with life promotion programs within Aboriginal communities.

It must be recognised that somech services. In the mental health context, people can be especially fearful of having a "psych file", as there are examples of these being used against them by lawyers, particularly in relation to the removal of children. This can provide a strong reason to avoid contact with services.
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I have seen things written in files that are racist and have gone against people. People are worried about stuff being written in their files that will be used against them. —Aboriginal health representative
For most Aboriginal and Torres Strait Islander communities, relapse prevention is best placed within an ongoing process of community development as determined by the community itself. This applies equally to urban, rural and remote communities. Many communities experience very high levels of stress in all domains: economic, environmental, physical, social and emotional stress. These sources of stress need to be addressed for all members of the community. Improving the general health and wellbeing of Aboriginal and Torres Strait Islander communities will improve the health and wellbeing of individual members and contribute to preventing relapse for those community members who have experienced mental illness. Only when the economic, environmental, physical, social and emotional wellbeing of communities are improved will there be real opportunities for relapse prevention for Aboriginal peoples and Torres Strait Islanders who have been seriously affected by mental illness.

Footnotes

3 Please note that the development of this section was strongly supported by a draft document by the Sheldon Remote Mental Health Team (2003) entitled, Leave Only Footprints. Cultural Sustainability and Mental Health in a Remote Aboriginal Setting. Sheldon Remote Mental Health Team, Alice Springs.