THE POLITICAL IS THE CLINICAL

1. THE POLITICAL IS THE CLINICAL Comfort zones, cultural safety and Indigenous ‘mental’ health MURU MARRI INDIGENOUS HEALTH UNIT

2. In Summary • MH services fail blackfellas in multiple ways • Re-conceptualising MH as well-being is likely to enhance outcomes, but mandates organisational change

3. In Summary • International indigenous experience offers clues, but there are crucial elements unique to the Australian situation • Change involves a suite of personal and political challenges, de-‘Othering’ and culturally safe practice

4. Indigenous Health Status • Worst of any group in Australia • Median age death (males) 51 yrs - 26 yrs < non-Indigenous • Life expectancy ↓ Maori, Aboriginal Canadian, Native American • Many conditions preventable

5. Mental Health Status • NSW figures: self-reported ‘mental distress’ almost 2 x non-Indig. rate • Specific diagnoses: depression, anxiety, bi- polar disorder, complex PTSD, borderline personality disorder, A&OD misuse, cannabis/amphetamine psychosis, but …

6. Focus on ‘Mental’ Health / Illness • History of incorrect diagnosis • History of medical complicity in eugenics movement, ‘locked’ hospitals, child removal and separatist political schemes • Negative, ‘deficit’ approach – ignores social, historical and cultural aspects, including resilience

7. Then

8. Now

9. I’m not ‘mental’ Narrow approach: no longer acceptable • Stigma • Lack of fit with Koori understandings • Ignores on-going loss and contemporary consequences of trans-generational trauma • Ignores the crucial contribution of exogenous, early psychic trauma

10. I’m not ‘mental’ • Psychobiology / Body memory of trauma – Bessel van der Kolk • Psychoneurobiology / Developing brain & trauma – Bruce Perry, Alan Schore • Intergenerational Trauma – Yael Danieli • Critical Psychology – Erika Apfelbaum • Critiques of Bio-Psychiatry – Peter Breggin

11. Indigenous Perspective • Blackfellas say fundamental connection between colonization and ‘mental distress’ • Holistic approach: mental health inseparable from overall health • Preferred term is social, spiritual and emotional well-being

12. Positive Approaches Jettison ‘Deficit’ Model, i.e. that: • Inherited factors explain most Indigenous Australian mental distress • The rest is sheer bloody-mindedness: ‘blacks behaving badly’

13. Positive Approaches • Attend to the social determinants of health: the role of history, politics, geography, culture and socio-economic status • Incorporate recognition of culture and the contexts of people’s lives into treatment/prevention

14. Towards an integrated model

15. Indigenous / CALDB well-being • Common aspects to working across Indigenous and CALDB populations? Yes • Same thing? No: unique aspects of Aboriginal and Torres Strait Islander situation

16. ‘First Nations’ Status • Aboriginal and Torres Strait Islander Australians occupy a unique position as the original inhabitants of Australia • Sovereignty has never been ceded or attenuated by treaty

17. Indigenous Health Status Effects of 200 years of colonization on health • Dispossession – land, language, culture, economic base → grief and loss • ‘Stolen Generations’ • Trans-Generational Trauma • Multi-Generational Chronic Stress • Racism, discrimination and ‘virtual’ apartheid

18. Colonization to healing • Clue from NZ MH competency framework ~ Specific reference to healing for Maori • Similar calls in Australia, but not mandatory - little recognition of: ~ Effects of colonization on health ~ Relationship of ATSI to land / spirituality ~ Sovereignty issue

19. Big picture: treaty and health

20. Big picture: culture and health • Connection to culture, language, land ‘protective’ of well-being (Aust./NZ, Jane McKendrick) • Notion of ‘Cultural Resilience’ (US, Iris HeavyRunner and Kathy Marshall)

21. Big picture: culture and health

22. Big picture: Cultural Presence Cultural Safety / Cultural Security affected by relative presence or relative absence of Indigenous culture in the life of the nation

23. Big picture: Minoritisation • Bruce Perry: psychologically fraught to leave the living culture of the reservation / whanau / Aboriginal community to become a ‘minority’ individual in a western cultural framework • Minoritisation = a reduction in regard

24. Big picture: Minoritisation • Does such ‘minoritisation’ multiply the effects of marginalisation? • When you’re already culturally absent / beyond the pale, does that make it even easier to become diminished or infantilised as a person?

25. Clinical picture: better praxis Ngara “Listen, hear, think … (Eora, the Sydney language) to listen is simultaneously to reflect and become self-aware.”* * Paul Carter

26. Clinical picture: better praxis Resonance with Cultural Safety Precept of health professional self- reflection / examination of own cultural system

27. De-Othering Indigenous Australia • Acceptance of alterity, small ‘o’ otherness • Cultural Imbrication / Cultural Interaction • Up-close-and-personal involvement • Everyday enmeshment, rather than policy fiat

28. Accepting small ‘o’ otherness

29. Extending our praxis To improve Indigenous social, spiritual and emotional well-being it’s time to: • Move beyond DSM IV • Move beyond diagnose / treat • Go further than the client / professional dyad

30. Extending the model

31. The political is the clinical • Aboriginal and Torres Strait Islander emotional well-being a complex endeavour • Need for positive approaches, a taking account of social determinants and grappling with unfamiliar imperatives: cultural competence / cultural safety / cultural imbrication

32. But … all this implies • Personal challengeto existing comfort zone • Professional challenge # To models of professional distance and non- disclosure # Mandates organisational change

33. But … all this implies • Political Challenge #Implications for training: systems/funding #Implications for competency standards # Implied need for increased practitioner advocacy

34. ‘Not For Service’ Rpt. Calls For • Funding: increase MH to 12 per cent of total health care funding • Policy: monitoring extent of MH problems PLUS A&OD integration with the National MH Strategy • Leadership and governance: federal Minister PLUS true collaboration between all stakeholders

35. ‘Not For Service’ Rpt. Calls For • Legal and Human Rights: nationally consistent guidelines on the provision of MH care • Workforce: urgently address the declining morale and chronic skills shortages in the MH workforce • Accountability: annual reporting mechanism on key indicators, including 10-year targets

36. The political is the clinical • Re-emerging role for public intellectual in conservative times • Australian Govt. denial of contemporary consequences of past practices leads to inequitable, ineffective policy • Time to re-conceive role of health professional as public professional

37. The political is the clinical • Governmental and organizational denial can be as unshakeable as alcoholic denial • Confrontation with evidence-base for fresh approaches to Indigenous well-being a necessary, but not sufficient condition

38. The political is the clinical • Clinical duty of care mandates a ‘political’ set of activities to circumvent denial • Could be pursued through changes to the parameters, language and tone of the debate • Requires practitioner involvement in creation of a parallel discourse

39. The political is the clinical Time for Boldness • Insist government policy founded-on contemporary effects of loss and TGT • Insist initiatives be funded according to need, are sustainable • Insist anything else violates professional duty of care