Is best practice really elusive when working with Indigenous populations?


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The philosophy around the development of an Indigenous Australian specific psychological service and discuss the obvious value with an approach which is based on extensive community engagement, ongoing validation of models and services, and importantly ensuring that a rigorous research methodology is applied to all aspects of service provision. Indigenous Australians have amongst the highest rates of mental ill health worldwide, but continue to have the lowest levels of access to mental health services.
Presentation by Dr Tracy Westerman, Managing Director, Indigenous Psychological Services, Western Australia at the 2009 SPINZ National Symposium: Culture and Suicide Prevention in Aotearoa:

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Is best practice really elusive when working with Indigenous populations?

  1. 1. Is Best Practice Really Elusive whenworking with Indigenous populations?Dr. Tracy WestermanManaging Director, Indigenous Psychological ServicesSPINZ National Symposium, 2009,Wellington, NZ
  2. 2. Who am I
  3. 3. Overview of IPS IPS CORE BUSINESS Community Organisation Psychological Training Research Prevention Cultural Change & Assessment Programs Development 12 Mental Health Recruitment &Brokerage Services ADHD Suicide Prevention specific packages Retention Services 12 packagesForensic, cognitive focusing on the Suicide Mediation & Comprehensive & compensation retention of Prevention Conflict Resolution Audits Indigenous people 4 Indigenous Indigenous specific Development of Trauma & Critical Specific assessment & Mental Health Incident Intervention intervention operational plans Indigenous specific Anger Management E-learning workforce Parenting skills development
  4. 4. A few dilemmas to highlight theproblems 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. 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. 6. Overview of Presentation1. An overview of the current mental health status of Aboriginal Australians2. Identify the priorities in developing best practice methodologies in mental health service delivery for Aboriginal people3. The work of IPS in developing models of effective practice in Indigenous mental health (and suicide prevention)
  7. 7. The State of Play• Misdiagnosis, overdiagnosis and underdiagnosis of mental health issues 1. Cultural Triggers not identified in mainstream assessments – but can we measure the relevance of culture? 2. Practitioner impacts – judging the absence or presence of disorder 3. Normality seen as abnormality – e.g. being sung/cursed, having spiritual visits of deceased loved ones versus psychosis (culture-bound syndromes)
  8. 8. What the current day looks like….1. Less likely to access mental health services2. Less likely to be identified as having a mental health problem – by services and community – “that’s just the way he is”3. More likely to engage for shorter periods and at chronic levels4. More likely to be treated with medication than any other form of therapy5. Isolation and treatment access – accommodation is greater6. External attribution belief system and problems7. Stigma regarding mental health
  9. 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. 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. 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. 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. 13. How this translates• Rates of mental ill health • suicidal behaviours, • depression, • self-harm, • PTSD??? • Dual diagnosis - alcohol and drug useage
  14. 14. What are the priorities in Aboriginal mental health?
  15. 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. 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. 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. 18. The role of IPS in finding some solutions…..
  19. 19. Solution: Development of Unique Tests & Assessments1. 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. 20. Unique Tests & Assessments2. Aboriginal Mental Health Cultural Assessment Models (Westerman, 2003) to enable diagnostic formulation across major disorders – spiritual visits or being sung; sorry cuts; longing for country3. 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. 21. Unique Tests & Assessments4. 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. 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. 23. Workforce and Organisational Cultural CompetenciesTied in with comprehensive cultural intervention including:2. Indigenous Specific Mental Health Training – 24 packages; 8,861 people trained since 20003. E-learning4. Culture-specific Client Policies and Procedures5. Cultural Review of Programs, Tests and Assessments6. Cultural Supervision Plans / Mutual Learning Contracts7. 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. 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. 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. 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. 27. Contact Details.Indigenous Psychological ServicesPO Box 1198 East Victoria Park WA 9681Phone 61 (08) 9362 2036Fax 61 (08) 9362 5546Email: