Culture,context and therapeutic processes: delivering a parent-child intervention in a remote Aboriginal community

Background

Let’s Start is part of a research program at the Menzies School of Health Research in Darwin, and demographic and outcome measures are collected for all participating children and families. It is currently delivered as a weekly program run over school terms, targeting four- to six-year-old children with identified emotional and behaviour problems which impact on their transition to school. The child attends with one caregiver (usually their mother), and the group is delivered by one or two members of the local community and two clinically trained and experienced professionals.

International studies have demonstrated the effectiveness and identified common elements of effective psychosocial treatments for children with behavioural problems.^1-4 This international literature informs the current version of Let’s Start. The program was adapted from the Exploring Together Program (ETP), originally developed as an outpatient program at the Austin Hospital in Melbourne. ⁵ Experience and evidence from a series of implementation trials on Bathurst and Melville Islands and in Darwin in the Northern Territory has enabled refinement and adaptation of the approach in a project led by author (GR).^6,7 Aspects of program development and adaptation have been described elsewhere.^8-11

The current program incorporates developmental information and behavioural parenting strategies along with reflective and expressive techniques and is informed by a combination of social learning, attachment, systems and narrative theories. Content and processes have been adapted for delivery in the remote Aboriginal context. The approach is not primarily didactic or educational. It follows a defined sequence of topics and activities while allowing scope for individual issues and group interactions. The current program structure consists of weekly sessions with a parents’ group in the first hour, followed by a parent-child interactive group and then a shared meal. This latter group incorporates songs, drawing and games into group and dyadic activities. The 10-week program is supported by an established process of community engagement maintained by a program coordinator who lives within the community at least half of the time.

This is a complex intervention delivered in a complex social and cultural environment. The program model and group leaders must be flexible enough to acknowledge and respond to the context, and to incorporate several therapeutic approaches and rationales into program delivery. The multi-group format aims to achieve change through complementary processes within the parents’ and interactive groups. It works with parents in relation to their parenting, their understanding of their child, their family relationships, their own mental states and, at times, their own family histories. In the interactive group the focus is on parent-child interaction, aiming to enhance enjoyment and cooperation and addressing miscommunication and conflict. The incorporation of a direct and observable focus on parent-child interaction and relationships makes Let’s Start (and ETP) unusual among parenting interventions.

The first author (SM) was employed from August to December 2010 and in 2011 in a visiting capacity, as a member of the team delivering Let’s Start, to facilitate the development of a program manual and further articulate clinical elements of the program, including clinical supervision. The second author (GR) has led the design and implementation of all aspects of the program since its inception.

The remote Aboriginal community context

Delivering Let’s Start in a remote community incurs intense time and resource costs far beyond the 10 weeks of program delivery. While the current program is described as a two-group model, it is in fact more complex, with the therapeutic elements operating within an extended program of community and family engagement.

Establishing a therapeutic setting

For group leaders delivering the program, travel to and from communities is time consuming and rarely straight forward.

On the 6th week of the program we arrived at Darwin airport at 730 am, as we had consistently every week for the previous 5 weeks, to find that despite a reminder phone call, the charter company had ‘forgotten’ our booking. We were offered a flight 3 days later and indicated that this would not do. An hour later a very small plane and pilot were located and we flew out 90 minutes late. Other mornings it was thunderstorms that caused delay or flights were cancelled because of storm or cyclone warnings. In previous weeks our colleagues based in another community had driven 2 hours to meet us, but the dirt roads had become increasingly dangerous in the wet, the punt had broken down and then the car needed fixing, so despite the cost, a plane was chartered.

On arrival we walked through the bush, past the art centre and Land Council to the school where the program was held. Two of the 6 parents had left when we were late and our allocated room was occupied by a visiting nutritionist. Eventually we found space and attempts were made to locate the parents and children. The dentist was in town for their 3 monthly clinic and one parent had gone to see him for toothache after several months waiting. Two parents were at a funeral in a nearby community. One community group leader, a teacher’s aide, was needed in the classroom. That day we ran the group with 3 of the 6 parents and their children and 3 of the four leaders.

It is the responsibility of group leaders to create and protect what can be described as the ‘therapeutic frame’, a predictable setting with consistent parameters within which the group work can occur. Changes in attitudes and behaviour and new understanding and experience involve a degree of personal reflection, disclosure and risk. As with any exploration, this requires that a sense of safety and trust be established within the group each week and over the course of the program. Traditionally therapeutic parameters are understood to require the therapist or group leader to behave reliably in practical and interpersonal ways – for example, being on time, and to establish and maintain group rules and act in ways that enable the work of the group and the focus of the session to be maintained.

Most parents and children attending the program have no prior experience of therapy or group-therapy interventions. They do not know what to expect and the situation is unfamiliar and potentially anxiety provoking. Many parents are shy and reticent, at least initially. Any potential sense of confrontation in the parents’ group is balanced by the child friendly atmosphere of the interactive group and a structure that ideally enables containment of parents’ anxieties about personal disclosure through an initial focus on concerns about their children. Group activities include drawing and storytelling to support parents and children in their participation.

In a remote Aboriginal community the capacity of group leaders to influence the many practical factors that impact on provision of a stable therapeutic environment is limited, and there is little experience or expectation within the community about what a predictable professional relationship might require from leaders or participants. To some extent community engagement over months and years, well beyond the 10-week group can be seen to provide a kind of reliability or ‘holding’ that is unique to this setting.

Professional boundaries and self-disclosure

Standard therapeutic approaches aim to establish clear professional boundaries in terms of self-disclosure within and outside the therapeutic encounter. This can vary when working in a remote Aboriginal community.

The first group began with a simple game to introduce parents and group leaders to each other. This meant giving our names but also providing personal information. Stories about where we were born, our families, how many children or siblings, nieces and nephews we had attracted most interest and recognition.

Descriptions of professional training or qualifications (often requested by non-Aboriginal participants in the Darwin program) appeared irrelevant or even alienating to the parents compared with one’s readiness to identify potential commonalities in relation, for example, to place or family.

Group participation and attendance

Events within the community affect parents, children and community co-leaders and also significantly influence attendance and the pace at which difficult issues can be explored.

Four funerals in the community over the school term impacted significantly on group members and community co-leaders both in their participation and their mood. This included the suicide of an 18 year old by electrocution, the premature delivery of stillborn twins, the death of a female elder from renal disease and the sudden death in a car accident of a middle-aged community leader. His death had a major impact on the community. For weeks there was a pervasive sense of grief within the community and several parents had obligations associated with the funeral, for example smoking the accident site and other places of significance, as well as their personal loss.

Funerals are all too common. Agreement can often be reached about whether to continue to run the program, cancel or change the day of delivery. However, work obligations, childcare, the need to leave for school, medical or sporting activities and visits to community by services and government, all have the capacity to disrupt attendance. Many of these issues need accommodating in any setting, but for families in remote communities they arise apparently unpredictably and frequently disrupt attendance and participation.

Language

Few Aboriginal communities are linguistically homogeneous. The language of program delivery is local Aboriginal English. Language differences between group members and ‘external’ group leaders (professionals from outside the community) have been accommodated by employment of local community members as co-leaders and the inclusion of songs and stories in local language. Parents and children vary in their use of Aboriginal or English languages and groups are run with a flow in and out of local language, with requests for translation necessary in both directions. Language is only part of cultural difference, and the outsider, running a therapeutic group in a small Aboriginal community, is outside not only in language but also in access to community relationships and a place within those relationships.

Culture and group relationships

Family structures, expectations about parenting, patterns of child rearing and relationships between group members are shaped by cultural and social context. A therapeutic program requires participants and group leaders to create a common understanding through dialogue, stories and action. This is the basis of the therapeutic alliance and the intervention in the Let’s Start program. Program strategies are chosen to give voice to Aboriginal parents and to encourage reflection in culturally accessible ways while at the same time incorporating elements common to mainstream interventions that are supported by evidence of their efficacy.

Relationships between group members

Styles of participation in remote Aboriginal communities impact on the functioning of the parents’ and the interactive group. All persons in remote communities are known to each other and are in acknowledged ongoing relationships of varying degrees of closeness. Children are usually in the group with classmates, often playmates outside of school and who may also be kin. In addition, many parents in the group are related as family or kin and this also applies to community group leaders. Such kin relationships include rules about who is able to talk or be close to whom, and for example who can tease whom. An outsider may know in theory about these relationships and prohibitions, but still be unaware of, or underestimate their contribution to, group processes. Likewise the histories that group members share even when not related, can be significant. For remote Aboriginal parents and their children, there is potential congruence between the interrelatedness of group members and the interrelatedness of people within the community and within the daily life of the child.

Working with community co-leaders

Let’s Start is delivered by one or two members of the local community who have been trained by the team and two ‘external’ professionals. There is turnover of both community members and professionals involved in delivering Let’s Start and group leaders have often not worked together before. The employment of local community members enhances accessibility and engagement of families with the program, supporting the ‘external’ leaders to understand issues relating to culture and kinship, conflicts between individual families and children, and other matters of community and cultural significance. Community co-leaders have relationships with local families, local knowledge including local language skills but have limited training or experience in therapeutic or psychosocial interventions. They also have relationships with participants that may impact on their participation.

One very able community leader had a kin relationship that entailed ‘avoidance’, with two mothers referred to a recent group. In order not to limit the parents’ participation, the leader adjusted his participation to allow for a greater social distance while others took up the close engagement required for group work.

While ‘external’ group leaders do not normally encounter these constraints, they are often for that very reason less attuned to relationships between parents and others and how these might subtly shape interactions. For example, the often indirect styles of communication that occur around topics involving reference to self or others reflect undisclosed relational distance between participants or between participants who are related to others not present, but which must be maintained. At its simplest, this is a very common issue: talking about oneself in a certain way may reflect on one’s spouse who is not present. If one’s spouse is related to others who are present (as a sibling, for example), this inevitably shapes the conversation and the directness or codes with which certain topics can be broached. The group leader from outside lacks the store of implicit relational and cultural knowledge that enables affective communication in relationship to others to be intuitively understood, and therefore worked with in the group.

The skills and deficits in experience and training of the professional group leaders are the inverse, with little local knowledge or language, but experience and skill in delivering interventions and in clinical work with children and families. These factors impact on interactions between group leaders and parents.

The importance of the community group leaders and their contribution to the work of the group, but also the transitional or bridging position they hold between parents and the external group leaders is illustrated in the following example.

There was discussion about how children learn, the consensus being that they don’t always listen if you try to tell them things or ‘growl’ (shout, tell off) at them. The following exchange occurred between the group leader (SM) and parents. Parent: ‘Kids learn by watching’. After some discussion about developing skills in hunting, cooking and so on, SM said ‘...and what if they see things or watch things we don’t want them to learn, like fighting or drinking?’ (There had been earlier talk about domestic violence and alcohol). There was silence. Then one parent said. ‘They learn it isn’t safe at home’. Another said, ‘They learn they can’t trust us’ and another, ‘They learn to fight and drink as well’. After a further silence, the community leader told a story about how when her children were young and when the club was open and alcohol available, she would pack up food and bedding and leave with the children to sleep either in the bush or at another house. ‘You can’t talk to drunk people. If they want to fight, it’s better to get out of the way’. Her story was moving and important. Drinking and violence happens. It had happened to her. Parents may not be able to change how other people behave but they can act to protect their children by moving to a safe place.

The community co-leader works on the basis of commonalities of experience, but individualises this through personal stories and accounts. The ‘outsider’s’ role is to manage these conversations and the feelings they arouse, so that they can be therapeutic, and to prompt and reframe the narrative based on common concerns about children and parenting, to empathise, gently challenge and to elicit further discussion and reflection for individual parents and the group.

Interactions within the parents’ group

Some interactions in the parents’ group resemble a family therapy session more than a group encounter because of all the implied teasing, intimacy and ambivalence they contain.

During a parents’ group, several women were talking animatedly in local language. A group leader (SM) noticed that one woman was very quiet, a bit withdrawn. This followed some mention of a sensitive issue for her, a perinatal loss. SM said, ‘I notice M is very quiet, do you think she is OK, does she want to be included or left alone?’ The community group leader responded, loudly, ‘Naaa she just wants attention’, at which everyone laughed, including the person in question.

Some of these women had known each other since childhood and the children called maternal friends ‘mother’. Over the course of the group it was evident that there was truth to the observation, M’s way of getting attention was to withdraw and fall silent. At this time and on other occasions humour and teasing were used to divert from, or ease, difficult periods in the group when, for example, sadness or shame might have been prominent. Established relationships between group members and the community leader altered interactions and communication within the group in unanticipated ways.

One day there was talk about what children might understand about a recent death and the sadness of the adults in their family and community. Suddenly one of the mothers asked the local group leader where she ‘got that pretty skirt’ and animated conversation followed about what good clothes could be found at a charity shop and ‘how pretty that one’ (one mother) was looking. After similar things happened one more than one occasion, the group leader (SM) remarked that we seemed to have jumped away from talking about difficult and sad things, that talking about the skirt was easier. Later she was roundly told off by the local group leader; ‘That is our way, if you push things there is too much sad feeling and shame. You should be more gentle.’ Her comments were appreciated and welcome, but also illustrated a familiar tension between exploring difficult or important topics as part of the program purpose, while at the same time respecting individual boundaries and being sensitive to local ways. In this case, with the death of a prominent elder, a burden of sadness and loss affected the whole community and made it difficult to focus on the nominated topic or issue for the group.

Given the burden of adversity within the community, there was rarely a time when there was not a recent loss or crisis of some kind, including conflicts between parents attending the group as well as with others in the broader community. Keeping the children and their experience in mind was a challenge when parental feelings were strong and the issues preoccupying. Effective group work extends to acknowledging the effect on individuals of the many difficulties they encounter in demanding and complex family and community relationships.

Conclusion

Cultural competence in early intervention programs and in staff necessarily extends from recruitment and training, to the logic of the intervention and its fit with patterns of interaction and relationships within a specific community. Relationships between parents attending the group, parents and group leaders, and parents and children, as well as expectations about development, parenting and about professional roles and responsibilities all impact on group processes. Professionals accustomed to work in urban settings are often both literally living outside the community but also ‘outside’ in terms of access to community relationships and a place within them. This can be considered both an asset and a limitation therapeutically. The complementary role of community co-leaders is crucial in assuring program accessibility but requires the ‘outsider’ to be flexible in their approach to group work with parents and children without abandoning a professional stance or program structure and content.

We have attempted to describe the impact of distance, culture and relationships in a remote Aboriginal community on the process of establishing a therapeutic framework, group processes and relationships between participants within a therapeutic parent-child program. Adaptation and evaluation, as well as staff recruitment and training, need to take these factors into account to ensure that the program is culturally accessible while maintaining therapeutic fidelity and efficacy.