Is Best Practice Really Elusive when working with Indigenous populations?

1. Is Best Practice Really Elusive when working with Indigenous populations? Dr. Tracy Westerman Managing Director, Indigenous Psychological Services SPINZ National Symposium, 2009, Wellington, NZ

2. Who am I

3. Overview of IPS

4. A few dilemmas to highlight the problems with mainstream approaches to suicide prevention • A traditional Aboriginal Australian is charged with the statutory assault of a 12 year old girl from an Aboriginal community – he is sentenced to two months in prison on the basis that he argues that the girl was ‘promised’ to him as part of a traditional marriage. The girl goes on to attempt suicide • Abuse or Culture?

5. And Mainstream approaches to Mental Health • An Aboriginal man is on trial for the murder of his traditional wife. He says that on the days leading up to the event he was being ‘sung’ (cursed) by cultural law men. The singing involved command hallucinations. He has no history of violent behavior. • Psychotic or culture-bound?

6. Overview of Presentation • An overview of the current mental health status of Aboriginal Australians • Identify the priorities in developing best practice methodologies in mental health service delivery for Aboriginal people • The work of IPS in developing models of effective practice in Indigenous mental health (and suicide prevention)

7. The State of Play • Misdiagnosis, overdiagnosis and underdiagnosis of mental health issues • Cultural Triggers not identified in mainstream assessments – but can we measure the relevance of culture? • Practitioner impacts – judging the absence or presence of disorder • Normality seen as abnormality – e.g. being sung/cursed, having spiritual visits of deceased loved ones versus psychosis (culture-bound syndromes)

8. What the current day looks like…. • Less likely to access mental health services • Less likely to be identified as having a mental health problem – by services and community – “that’s just the way he is” • More likely to engage for shorter periods and at chronic levels • More likely to be treated with medication than any other form of therapy • Isolation and treatment access – accommodation is greater • External attribution belief system and problems • Stigma regarding mental health

9. What role history has played… • Population of over 1 million prior to 1788, declined to 30,000 by the 1930’s • Social policies • Assimilation until 1972 • Exclusion from education until 1960’s • Exclusion from parenting support benefits until 1970s • Citizenship rights in 1960’s • Classified under flora and fauna until 1960’s • Prohibition until the 1970s

10. And continues to play….. • Aboriginal people constitute 2.2% of the Australian population of approx 20 million • Most disadvantaged on every social indicator • Life expectancy 20 years less than NA (average is mid 50) • Infant mortality is three times that of NA Australia • Fourth world conditions • Denial of History (refusal to say sorry) under Howard Liberal Govt from 1996 - 2007 • Validation of trauma – why ‘sorry’ was not the hardest word after all • How this maintained trauma and difficulty in healing

11. Impacts of Stolen Generations • Acculturative stress and marginalisation • Premature death and compounded grief • Forcible removal – loss of parental models and practices • Cultural parenting strategies are seen as deficient by mainstream • Removal leads to difficulty in developing healthy attachments • Ability to respond to the range of positive and negative emotions in our own children

12. Impacts of Stolen Generations • Intergenerational Impacts • Mental illness and genetics/environment • More likely to experience intra-familial abuse leading to greater risk for PTSD and difficulty with healing • Changes to cultural practices • The role of payback (customary law) in dealing with non-traditional issues (i.e. assault and suicides) • Sorry time and cultural grieving for suicide

13. How this translates • Rates of mental ill health • suicidal behaviours, • depression, • self-harm, • PTSD??? • Dual diagnosis - alcohol and drug useage

14. What are the priorities in Aboriginal mental health?

15. Priority 1: Reliable and Valid Assessments & Tests • Impacting on • Are the assessments culturally valid? Construct? Face? Cultural? • Does the assessment take into account the cultural relativity of behaviour? E.g of ADHD; spiritual visits • Evidence for trends in tests with minority populations e,g. Depression measures; MMPI; CBCL • Different symptom base for disorders across cultures (Westerman, 2003; Allen, 1998; Manson, 1995)

16. Priority 2: Improving on access to appropriate services • Cultural Competence is ill defined and not measurable becoming the ‘poor cousin’ to clinical competence • Leads to Organisations grappling with how to embed cultural competence in all aspects of service delivery • No clear pre requisite skills in working with Aboriginal people in a mental health capacity

17. Problem: Inequities in research and Indigenous specific mental health intervention programs • Prevalence rates range from 1.8%, to 51.2% • Limited prevalence data and lack of representation of Aboriginal people in epidemiological studies • Research always suggests a mainstream view of risk, resilience and aetiology • No published research into the efficacy of traditional treatments, mainstream counselling, therapies or intervention programs with Aboriginal people • Predominant “Absence of Evidence” view in relation to the existence of culture-bound syndromes

18. The role of IPS in finding some solutions…..

19. Solution: Development of Unique Tests & Assessments 1. The Westerman Aboriginal Symptom Checklist - Youth (WASC-Y: Westerman, 2003) and WASC-A, resulting in: • Identify early stage of risk • Population level data specific to Aboriginal people on the nature of suicide • Valid prevalence data • Information on co-occurrence of disorder • Able to evaluate efficacy of intervention

20. Unique Tests & Assessments 2. Aboriginal Mental Health Cultural Assessment Models (Westerman, 2003) to enable diagnostic formulation across major disorders – spiritual visits or being sung; sorry cuts; longing for country 3. Acculturative Stress Scale for Aboriginal Australians (Westerman, 2003) • Relationship with risk –15% of variance for psychological symptoms accounted for by culture stress • Mental health outcome. The focus is on reducing culture stress

21. Unique Tests & Assessments 4. The Acculturation Scale for Aboriginal Australians (Westerman, 2003) • Provides cultural evidence for disorder – e.g. command automatism; possession psychosis etc., so that ethnic or racial heritage is concretised rather than an amorphous construct (Tseng, Matthews & Elwyn, 2004; Diamond, 1978) • Gauges the extent of connection with culture / beliefs relative to other Aboriginal people (Westerman, 2003) • Forces practitioners to explore a cultural basis for all illness • Addresses the issue of test bias • Community then provides collateral information to support assessment/diagnosis

22. Solution: Workforce and Organisational Cultural Competencies • Determined the predictors of cultural competence via the Aboriginal Mental Health Cultural Competency Test (CCT: Westerman, 2003, 2009 in prep) • Knowledge • Beliefs and Attitudes • Skills & Abilities • Resources and Linkages • Organisational Cultural Competencies • Objective, measurable over time and compared with national norms

23. Workforce and Organisational Cultural Competencies Tied in with comprehensive cultural intervention including: • Indigenous Specific Mental Health Training – 24 packages; 8,861 people trained since 2000 • E-learning • Culture-specific Client Policies and Procedures • Cultural Review of Programs, Tests and Assessments • Cultural Supervision Plans / Mutual Learning Contracts • Development of Indigenous Mental Health Service Delivery Models in which SP’s need to attain a ‘black card’ of cultural competence and community then oversee the ongoing delivery of the program

24. Solution: Culturally Driven and Valid Research • Evidence based practice for disorders via population level data – e.g. of Aboriginal suicide • Validation of CB syndromes • Adaptation of Counselling Micro-skills - e.g. self-disclosures; gratuitous concurrence • Adapt therapies to incorporate cultural differences in learning styles – visual memory • Determine the role of mainstream therapies in treating CB syndromes e.g. longing for country • Validation of traditional treatment hierarchy • Cultural evidence for organisational policies relative to cultural norms e.g. second/third hand referrals/cultural vouching for engagement

25. Solution: Developing Community Capacity – whole of community suicide intervention programs • Demand for forums from community • Unique content • Three different groups – SP’s, community & youth • Training for SP’s and psycho-education for youth & service providers • Outcome driven evaluations demonstrating consistently statistically significant increases focusing on: • Skills increases • Knowledge • Intentions to assist • High risk regions and potential for risk targeted • 8 regions since July, 2002 delivered over 3 phases • Over 1,800 trained – 85% Indigenous

26. Where to from here? • We need to continue to improve diagnosis, prognosis and intervention • Replicate models for use with other presenting issues • Transferability across different groups • Longitudinal data to determine impacts • Ensure that cultural competency becomes a minimum standard • Continue to facilitate community development of unique programs, models and services which challenge mainstream constructs of mental health

27. Contact Details. Indigenous Psychological Services PO Box 1198 East Victoria Park WA 9681 Phone 61 (08) 9362 2036 Fax 61 (08) 9362 5546 Email: ips@ips.iinet.net.au Website: www.indigenouspsychservices.com.au