Advancing social and emotional well-being in Aboriginal and Torres Strait Islander Australians: Clinicians’ reflections

Cultural aspects of psychiatric care

The Ways Forward report reminded readers of an important holistic construction of health promulgated by the World Health Organization that has since become central to Indigenous understandings.

Health does not just mean the physical well-being of the individual, but refers to the social, emotional and cultural well-being of the whole community. This is a whole of life view and includes cyclical concept of life-death-life. Health care services should strive to achieve the state where every individual can achieve their full potential as human beings and thus bring about the total well-being of the communities. ³

Spirituality, ancestry and country are essential to Indigenous identity and culture, providing sources of knowledge and wisdom. However, contemporary health care remains dominated by biological paradigms that do not capture the complexity and cultural aspects of Indigenous approaches to health and well-being, neglecting the wisdom that an ancient culture offers. Indigenous society encompasses structures providing support, establishing accountability and guiding development. The interplay between the individual and the community is critical, as each person has culturally-informed roles and obligations. Health, educational and correctional institutions cannot replace these structures, and investing further in conventional institutional responses is not sufficient to address the challenges that Indigenous societies now face. Rather than imposed structures, a collaborative approach with Indigenous people is critical to expanding our own experience and effectiveness. The humanistic and cultural elements of health care must remain central to service provision.

Focus on young people: trauma, resilience and post-traumatic growth

Regardless of mainstream affirmation of this holistic construction, across key divides (Indigenous/non-Indigenous; economically privileged/disadvantaged; institutionally empowered/disempowered) within the spaces allocated for ‘treatment’ (not to be confused with ‘healing’), mutual agreement and understanding remain uncommon. Maintaining effort to improve intercultural efficacy remains an ongoing task at the health service/practitioner level. However, given the persistence of these divides and the burden of social determinants, it is clear that well-being for individuals, families and communities will not result from health sector activities alone, demanding practitioners embrace additional roles in the longer-term social project of improving Indigenous lives and livelihoods. This is particularly important in responding to the needs of the most at risk – children and youth who are disengaged from the critical developmental stabilisers of family and school – requiring collaboration with departments and agencies in the community and social services.

This is particularly important given the crisis of Indigenous youth suicide and self harm, and increasing rates of incarceration of Indigenous youth reflecting developmental adversity and its existential consequences. The loss of culture, identity, values and goals, and the clustering of despair and grief in Indigenous communities inhibit the development of coping skills and resilience. Indigenous youth culture is in flux and includes a hybrid mix of traditional and modern values; many Indigenous youths identify with fragmented Indigenous identity-referents, Afro-Caribbean ideals, and values and attitudes represented through the media. Clinicians should be alert to contemporary trends in online activities that may provide both more comprehensive understanding and also opportunities to engage and support those at risk.

Despite the burdens of history and social context, at the clinical interface there is no room for fatalism. Facilitating ‘post-traumatic growth’ is an important step in improving social and emotional well-being and useful strategies include the concept of ‘meaning making’, a narrative-based approach to fostering resilience, exploring cultural strengths and harnessing cultural constructs through interactive techniques such as yarning circles, art, music or dance. A multimodal approach to social and emotional well-being should include more emphasis on mental health literacy, social support and trauma-informed care, facilitated but not replaced by technology and social media. The strengths of communities, often derived from elders and senior members, should be incorporated.

Diagnosis and assessment

Without a nuanced understanding of the circumstances and beliefs of the local Indigenous group, mental health assessment presents significant risks. Assessment requires informed judgement and should avoid the perils of, on one hand, culturally-rationalising psychopathology and, on the other, pathologising culture. For example, lack of cultural awareness may lead to misdiagnosis when a person reports hearing voices in the context of grief or healing practices and such experiences may be misinterpreted as psychosis, delusional ideation or grandiosity. Trauma and grief can present with anger, aggression, frustration, emotional numbness and depersonalisation, and trauma-related dissociative states may be misdiagnosed as a mixed affective-psychotic disorder. The concept of personality disorder remains to be more clearly understood in Indigenous contexts where a significant majority of the community has experienced trauma.

Assessment requires sensitive exploration of the individual narrative and experience-based judgement. This sometimes benefits from being undertaken in short episodes over a period of time rather than the traditional lengthy psychiatric diagnostic interview and is a process which may be supported by cultural supervision. In other cases, lengthy interviews may facilitate a free-flowing narrative, accommodating silence as communication, and not constrained by the conventions of a structured psychiatric interview. Involvement of the broader family and community network is crucial to comprehensive assessment and to enhancing shared understanding and patient-focussed care in an Indigenous context. To that end clinical concepts and treatment issues need to be conveyed clearly without trivializing content.

Workforce

Trust and mutual respect are essential if Indigenous Australians are to engage with health providers. However, many health services struggle to recruit and retain long-term staff, particularly in disadvantaged rural and remote locations where there is increasing reliance on locum staff, some with little orientation to local practices and issues. Cultural awareness training and online modules, which are mandated in some services, are not sufficient to ensure ongoing reflection and respectful relationships. Furthermore, experience is not necessarily transferable; Indigenous culture is not homogenous, and a local educational cultural programme is imperative – insufficient consideration of local Indigenous context and practices leads to uncritical assumptions and untheorised interventions. Cultural support and supervision need to be ongoing, based on reflection and self-directed learning, and with attention to local nuances and values. It should ensure clinicians recognise the value of cultural knowledge and the strengths of Indigenous communities including their emerging leaders. Despite significant social disadvantage, Indigenous Australians have clear aspirations, they recognise that the trans-generational history of trauma, loss and grief does not define them. Relationships between healthcare professionals and Indigenous communities have evolved over many years, reflecting social and political forces as well as the nature of healthcare services. They will continue to do so.

Improving systems of care, leadership and advocacy

The multitude of systems of care funded by state and federal governments, including basic health services as well as special projects and programmes, has resulted in competition, confusion, stagnation and poor coordination. Multiple providers and unsustainable project-funded interventions further entrench experiences of marginalisation and disempowerment. With the retreat of the public sector from direct service provision the need for coordination between local health services, Aboriginal health services, hospitals and general practitioners across remote, regional and metropolitan areas is critical.

Regardless, while it is not possible to ensure specialist expertise based within every remote community, it is possible to improve coordination of information and effort by sharing records and identifying at-risk individuals. At the client interface, navigating the health system is a significant challenge for many Indigenous Australians who may choose to avoid engagement rather than an alienating and culturally-insensitive system. That also needs to change and, to those ends, strong professional leadership is essential and needs to engage local community members and elders and value their cultural knowledge and priorities.

All psychiatrists should value and promote the role of Indigenous mental health workers as clinicians and as cultural consultants. Providing a culturally-safe work environment for the Indigenous health workforce, allowing and supporting ongoing professional development and providing a career structure will assist. ‘Aspirational’ goals for health services of clinical and executive staffing in parity with the proportion of Indigenous people in the Australia population (approximately 3%) should be achievable. The unique experiences of Indigenous psychiatry trainees need further exploration and the development of targeted interventions through the College to support Indigenous medical students should include building institutional relationships with the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors’ Association (AIDA).

The RANZCP Aboriginal and Torres Strait Islanders Mental Health committee has developed a series of online e-learning modules. Completion of the programme is mandatory for trainees, and consultants would also benefit from viewing the resource. Other RANZCP activities and resources include the Reconciliation Action Plan, position statements promoting the role of Indigenous mental health workers, and support and advocacy for increasing Indigenous participation within College staff and the training committee.

Conclusion

More than two decades since the Ways Forward report, much remains to be done. Although there are improvements in some areas, the social drivers for mental health problems reflect the need for sustained, culturally-appropriate interventions in complex cultural, social and political environments. We note the need for continuing policy and practice refinement, particularly with respect to Indigenous inclusion in the medical workforce, focussing on the need for cultural supervision, and a youth-focused approach to Indigenous mental health care.