National Guide

Chapter 20 | Mental health

Introduction







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      1. Introduction

Introduction

Dr Timothy Senior  
 

Background

The refreshed National agreement on closing the gap1 in 2020 established formal partnerships and joint decision making between governments and Aboriginal and Torres Strait Islander people, with a new set of 19 national socioeconomic The refreshed National agreement on closing the gap1 in 2020 established formal partnerships and joint decision making between governments and Aboriginal and Torres Strait Islander people, with a new set of 19 national socioeconomic targets. Outcome Number 14 is ‘Aboriginal and Torres Strait Islander people enjoy high levels of social and emotional wellbeing’.1 The target indicator for this measure is ‘Significant and sustained reduction in suicide of Aboriginal and Torres Strait Islander people towards zero’.1

Importantly, the terminology used in the Closing the Gap partnership, and used widely among Aboriginal and Torres Strait Islander people is ‘social and emotional wellbeing’ (SEWB). This is sometimes inaccurately considered to be synonymous with the term ‘mental health’, and although there are areas of overlap, the concepts have different cultural underpinnings and conceptions of health and wellbeing.
SEWB implies a holistic, strengths-based approach and is distinguished from a disease-oriented medical model (see Box ] ).

Box 1. Concepts of social and emotional wellbeing
In broad terms, SEWB is the foundation for physical and mental health for Aboriginal and Torres Strait Islander people. It is a holistic concept that results from a network of relationships between individuals, family, kin and community. It also recognises the importance of connection to land, culture, spirituality and ancestry, and how these interact and affect the individual.

SEWB may change across the life course: what is important to a child’s SEWB may be quite different to what is important to an Elder. However, across the life course, a positive sense of SEWB is essential for Aboriginal and Torres Strait Islander people to lead successful and fulfilling lives.2,3

SEWB is a key component of the Aboriginal definition of health, includes concepts of connection to Country, kin and community and is applicable across the whole lifecycle.4,5 However, much of the research in this area is done in settings outside of Aboriginal and Torres Strait Islander communities, without Aboriginal and Torres Strait Islander ownership, and is grounded within a more Western, individualistic, medical model of health. As such, inclusion criteria and outcomes are determined by Western-centric diagnostic categories, such as those in the Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR),6 that do not incorporate Aboriginal and Torres Strait Islander perspectives (see Box 1). In looking at evidence to make recommendations for the prevention of depression and suicide, this chapter recognises there can be tensions between biomedical- and Aboriginal and Torres Strait Islander-oriented concepts of mental health. These are the same tensions experienced by healthcare practitioners who, in preventing, diagnosing and managing conditions based in a mental illness paradigm, need to recognise, incorporate and balance understandings of SEWB into their care in order to provide optimal, culturally safe care.

It is important to recognise that the term ‘mental health’ has negative connotations for many Aboriginal and Torres Strait Islander people for a number of reasons. These include, but are not limited to:

  • many families having negative experiences with the way their loved ones have been managed in the biomedical psychiatric treatment model (eg trauma associated with use of the Mental Health Act)
  • the lack of recognition of Aboriginal and Torres Strait Islander peoples’ cultural and spiritual worldview in interpreting symptoms (eg hallucinations/seeing Ancestors and Spirits in some forms is not unusual)
  • community stigma towards some mental health disorders.

For these reasons, health practitioners should be aware of local conventions and preferences in the use of this terminology. The best way to ensure this is to work with local Aboriginal and Torres Strait Islander health practitioners, health workers and other health professionals whenever possible.

Trauma occurs when a person’s coping capacity is overwhelmed by the experience or perception of severe threat. Trauma can be experienced at an individual level, such as the complex trauma due to childhood adversity7,8 and following specific frightening incidents. For Aboriginal and Torres Strait Islander people, the experience of trauma is expanded through the historical effects of colonisation. Colonisation creates intergenerational trauma due to ‘dispossession from land, forced removal of Indigenous children from families, and institutionalised racism’.9 The perception of threat from colonisation may not be severe in the moment, but it is chronic and deeply felt across communities and generations. It therefore compounds the effects of trauma arising from individual traumatic experiences. Intergenerational and collective trauma has been shown to affect the nervous system, contribute to chronic physical health problems and influence the social determinants of health.

According to Productivity Commission estimates based on Australian Bureau of Statistics data, 75% of Australian adults have experienced some form of trauma in their lifetime.10 In Aboriginal and Torres Strait Islander communities across southern Queensland and northern New South Wales, 65% of people had experienced trauma in their lifetime, with 62% experiencing more than one trauma.11 This puts an onus on healthcare practitioners to practise in a way that is trauma informed, especially when we may be raising issues of mental health and SEWB without the patient bringing it up themselves in a prevention setting.
 
Practitioners should be alert to the potential of a history of significant trauma in people attending a health service, and that they may not be ready to disclose this, or talk about the detail, and that being encouraged to discuss previous trauma when they are not ready can be harmful, setting back their recovery. This requires care in the referral process to minimise the need for people to retell their story, which can be deeply triggering and retraumatising. Practitioners should also be aware of intergenerational and collective trauma and the impact this has on the therapeutic relationship in gaining trust and rapport. Practitioners are again encouraged to seek support from local Aboriginal and Torres Strait Islander health professionals in understanding and mitigating this. Practitioners cannot rely on trust developing automatically, and often need to take active steps in the consultation to engender trust and rapport. There are many Aboriginal and Torres Strait Islander organisations and resources that offer training in trauma-informed care to facilitate this.
 
The detection and treatment of complex trauma is beyond the scope of this guideline and, although many primary care health practitioners will not be providing specific treatment for trauma, all practitioners should take a trauma-informed approach with their patients*. This includes the general communication skills required for all consultations, in providing professionalism, medical expertise and a warm manner.
 
Key principles for trauma-informed care for Aboriginal and Torres Strait Islander people outlined by Dr Carmen Cubillo, coordinator of the Damulgurra program of cultural safety training in the Northern Territory are to:

  • support relationship building and connectedness as a means to promote healing
  • understand trauma and its impacts
  • understand privilege and the dynamics of power (cultural safety)
  • create environments in which staff, patients and community members feel physically, emotionally and spiritually safe
  • empower and support patients in their journey of healing and recovery
  • integrate and coordinate care to holistically meet the needs of individuals’ families and communities.12
These principles are consistent with those outlined by the Blue Knot Foundation:13
  • active listening and validation of the person’s experience
  • providing an environment and interaction that enables the person to feel physically and emotionally safe
  • trustworthiness
  • providing choice to the person about options available to them
  • collaborating with the person
  • empowering the person.
It is not unusual that the sense of safety has to be established repeatedly. The setting in which care is provided is also important in being able to establish a trauma-informed approach to care.

*Note that while acknowledging that some services may prefer the term ‘client’, this chapter uses the term ‘patient’. This is consistent with the rest of the National Guide and does not change any of the recommendations.

 

The forced removal of Aboriginal and Torres Strait Islander children from their families through race-based policies of state and federal governments from 1910 through to the 1970s had a profound effect on the health and SEWB of those removed, and subsequently on their children.14 Although this may not be disclosed to health practitioners, practitioners need to be aware of the effect of these policies, including in the way in which they have affected trust in institutions, including health services and health professionals. Although these official policies are now discontinued, removal continues at a high level through child protection policies, and the result of this on the SEWB of children, adolescents and adults of all ages, and subsequent generations, is currently unknown.

The Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Sistergirl and Brotherboy (LGBTQIA+SB) community are affected by racism and colonisation, as well as homophobia and other gender- and sexuality-related phobia, with a compounding of the effects on health and SEWB.15 The protective effects of a supportive and empowering community are an important source of power and help seeking. Many Aboriginal and Torres Strait Islander communities are very accepting of gender diversity and can be a source of strength to connect with community and kin. Health services and healthcare practitioners need to be aware of this intersection, and identify and celebrate the diversity among their patients, to enable discussions about mental health experiences without fear, and to be able to tailor the most appropriate care for each person.

Working with people experiencing problems with mental health puts health professionals face to face with suffering. Perhaps more than in other areas of healthcare, health professionals relate to people with mental health problems with empathy, with the consequent emotional impact. This may be further compounded when practitioners are isolated, through geography, distance from friends and family or by sheer workload and long hours, and where practitioners are working in the communities in which they live. Without acknowledging or managing this, as well as the potential for personal harm and burnout, the quality of care is adversely impacted.
Individual practitioners are encouraged to ensure they participate in activities that maintain their physical and mental health. This involves ensuring self-care during the working day and self-care activities outside work. The same as for our patients, this includes eating healthily, limiting alcohol intake, having regular physical activity and participating in enjoyable family and community activities, and ensuring we are connected to our own cultures. In addition, practitioners should consider psychological supervision, Balint groups (which discuss psychotherapeutic aspects of patient care) or peer support. However, all self-care activities require supportive environments, and members of the primary healthcare team will all benefit from looking after each other and working as a team to ensure that each team member feels valued and looked after. For the service as a whole, ensuring that staff are well and healthy, and are finding joy and meaning in their work, enhances the quality of care and services provided.16
 

  1. Closing the Gap. National agreement on closing the gap. Department of Prime Minister and Cabinet, 2020 [Accessed 24 May 2023].
  2. Gee G, Dudgeon P, Schultz C, Hart A, Kelly K. Social and emotional wellbeing and mental health: An Aboriginal perspective. In: Dudgeon P, Milroy M, Walker R, editors. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Telethon Kids, 2014; p. 55–68 [Accessed 28 May 2024].
  3. Department of Prime Minister and Cabinet. National strategic framework for Aboriginal and Torres Strait Islander peoples’ mental health and social and emotional wellbeing 2017–2023. National Indigenous Australians Agency, 2017 [Accessed 28 May 2024].
  4. Tjalaminu M, Dudgeon P, Mascall C, Grogan G, Murray B, Walker R. An evaluation of the national empowerment project cultural, social, and emotional wellbeing program. J Indig Wellbeing 2017;2(2):33–48.
  5. Dudgeon P, Blustein S, Bray A, Calma T, McPhee R, Ring I. Connection between family, kinship and social and emotional wellbeing. Australian Government, 2021 [Accessed 28 May 2024].
  6. American Psychiatric Association (APA). Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. APA, 2022 [Accessed 28 May 2024].
  7. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14(4):245–58. doi: 10.1016/S0749-3797(98)00017-8.
  8. Nelson CA, Scott RD, Bhutta ZA, Harris NB, Danese A, Samara M. Adversity in childhood is linked to mental and physical health throughout life. BMJ 2020;371:m3048. doi: 10.1136/bmj.m3048.
  9. Dudgeon P, Walker R. Decolonising Australian psychology: Discourses, strategies, and practice. J Soc Polit Psych 2015;3(1):276–97. doi: 10.5964/jspp.v3i1.126.
  10. Australian Institute of Health and Welfare (AIHW). Stress and trauma. AIHW, 2024 [Accessed 28 May 2024].
  11. Nasir BF, Black E, Toombs M, et al. Traumatic life events and risk of post-traumatic stress disorder among the Indigenous population of regional, remote and metropolitan Central–Eastern Australia: A cross-sectional study. BMJ Open 2021;11(4):e040875. doi: 10.1136/bmjopen-2020-040875.
  12. Cubillo C. Trauma-informed care: Culturally responsive practice working with Aboriginal and Torres Strait Islander communities. InPsych 2021;43(3) [Accessed 28 May 2024].
  13. Blue Knot Foundation. Understanding complex trauma. Blue Knot Foundation, 2021 [Accessed 24 May 2023].
  14. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Stolen Generations and descendants: Numbers, demographic characteristics and selected outcomes. AIHW, 2018 [Accessed 28 May 2024].
  15. Day M, Carlson B, Bonson D, Farrelly T. Aboriginal & Torres Strait Islander LGBTQIASB+ people and mental health and wellbeing. Australian Institute of Health and Welfare, 2023. doi: 10.25816/nmvs-nc70.
  16. Sikka R, Morath JM, Leape L. The quadruple aim: Care, health, cost and meaning in work. BMJ Qual Saf 2015;24(10):608–10. doi: 10.1136/bmjqs-2015-004160.




 

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