Better health and ageing for all Australians

Evaluation of the Bringing them home and Indigenous mental health programs

1.10 Good practice

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The literature on good practice indicates that:

  • it is critically important for mental health services to be provided to Aboriginal people in a culturally appropriate manner, through use of traditional healing approaches and ensuring that mainstream mental health services are delivered in this manner
  • there is some literature describing good practice approaches to Aboriginal SEWB services, but very little that refers specifically to provision of services to people affected by forcible removal practices (the key exception is the Marumali Program).

1.10.1 Culturally appropriate practice

It is widely acknowledged in the literature that there is a need for cultural awareness, sensitivity and appropriateness in mental health service provision for Aboriginal people (Koolmatrie & Williams 2000; RANZCP 2002; Westerman 2004). Indeed, this issue was specifically raised in the BTH Report, which noted that without culturally appropriate mental health services, critical problems arise relating to misdiagnosis, consequent inappropriate treatment, or failure to treat altogether (HREOC 1997, p321).

The literature identifies two key strategies for ensuring culturally appropriate treatment – namely the need for greater recognition of traditional healing methods and approaches, and also ensuring that 'mainstream' mental health service delivery is more culturally appropriate for Aboriginal clients. There is some contention regarding the latter approach however, as some writers have argued that attempting to employ a non-Aboriginal mental health system, which is essentially mono-cultural, with Aboriginal people is a form of racism (Waldegrave 1985). Others have viewed the Western use of psychotherapy with Aboriginal people as a form of colonisation (Tapping 1993).

While both of these needs are widely acknowledged in the literature, numerous authors have observed that there is a dearth of published material regarding effective preventative programs, therapeutic interventions with Aboriginal peoples, and studies providing a detailed and practical insight into the Aboriginal worldview (Westerman 2004; Vicary and Bishop 2005). In particular, there is a lack of material that outlines Aboriginal beliefs relating to psychotherapy, mental health and non-Aboriginal counsellors and therapists. Westerman observes that the paucity of published examples has affected service delivery at the individual clinical level and at broader system levels, 'the combined effect being inequity in access to mental health services by Indigenous people' (2004, p1). While examples of good practice exist (some examples are provided in this report at sub-section 1.9), there is no central collection point for these resources, nor is there any method for sharing this information with mental health practitioners so as to provide opportunities for 'empirical and cultural validation or replication across different contexts' (Westerman 2004).

In order to increase access to mental health services by Aboriginal people, Westerman argues that there is a need to integrate 'specific cultural and clinical competencies within the system and practitioner levels' (2004, p2).

At the same time, other literature suggests that traditional approaches are widely used in Aboriginal communities and that the role of the traditional healer has been and continues to be an important one (Dudgeon 2000; Vicary and Bishop 2005). Recent research by Vicary & Bishop (2005) indicates that Aboriginal people in some communities may access Western or mainstream mental health services 'only when all traditional avenues had been exhausted and there was no other treatment option available' (2005, p11). Participants in the research reported that they believed that Western psychotherapy lacked validity when used with Aboriginal clientele, and that they generally perceived Western style therapy as culturally inappropriate or irrelevant. Top of page

Vicary and Bishop have identified a number of treatments that Aboriginal people from the Kimberley would either use prior to or exclusively of Western treatments. The hierarchy consisted of:
  • support, advocacy, yarning, practical advice from immediate family members
  • assistance from extended family members
  • assistance from the community and Elders
  • a return to country to make a spiritual reconnection with the land
  • referral to a spiritual healer for specialist assistance (Vicary and Bishop 2005, p13).
The study indicated that, although the participants generally preferred to use traditional or Aboriginal-specific services, there was also recognition that at times accessing Western mental health services may be required for confidentiality purposes or because of a lack of traditional or same-culture services. The authors therefore recommended that non-Aboriginal practitioners should make themselves aware of traditional practices and processes for the treatment of mental health difficulties.

Similarly, Westerman (2004) suggests that there is a need to acknowledge existing frameworks of healing within Aboriginal communities and in particular those relating to treatment of culture-bound disorders, for example by: offering Aboriginal clients the option of traditional methods of healing as a primary treatment; recognising and respecting the traditional processes that exist for Aboriginal people to resolve mental health problems; and facilitating traditional methods of healing through engaging with traditional healers and cultural consultants (Westerman 2004, p5).

Various good practice guidelines have been developed which are of relevance to Aboriginal mental health. These include the:
  • National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH) 2003-2013 (Australian Health Ministers' Conference 2003)
  • National Strategic Framework for Aboriginal and Torres Strait Islander People's Mental Health and Social and Emotional Wellbeing 2004-2009 (Social Health Reference Group 2004)
  • National Practice Standards for the Mental Health Workforce (Department of Health and Ageing 2002)
  • Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004-2009 (Australian Health Minister's Advisory Council on Aboriginal and Torres Strait Islander Health Working Party 2004)
  • RANZCP Position Statement #50, Aboriginal and Torres Strait Islander Mental Health Workers (Royal Australian and New Zealand College of Psychiatrists 2002).
The two National Strategic Frameworks identify a number of key good practice principles in relation to Aboriginal health and mental health/SEWB respectively. Some of these principles of greatest relevance to the delivery of the four programs being evaluated here include: cultural respect to ensure that Aboriginal people's diversity, rights and values are respected; recognising and promoting Aboriginal concepts of holistic healing; promoting community control of primary health care services; responding to grief, loss, anger, and Stolen Generations issues; effective coordination of services with other agencies and planning processes, including facilitating improved access and responsiveness of mainstream mental health care for Aboriginal people; ensuring staff with appropriate skills are recruited, retained and supported through ongoing training; and collecting, analysing and publishing data to evaluate programs in a way that enables comparison across jurisdictions and use of the data to improve service delivery.Top of page

1.10.2 Good practice - training and professional development

As discussed above, various authors have observed that there is no central collection point or method of dissemination for examples of good practice in Aboriginal mental health service provision or therapeutic approaches. During the course of the evaluation the consultants were referred to a number of examples of good practice in service provision, relating to both training and professional development and therapeutic approaches. A brief outline of these examples is provided below. It should be noted however that this is by no means an exhaustive list.

Djirruwang Aboriginal and Torres Strait Islander Mental Health Program

The Djirruwang Program at Charles Sturt University (CSU) delivers a three-year Bachelor of Health Science (Mental Health) degree, with exit points at Degree, Diploma and Certificate levels. Course entry is restricted to Aboriginal people. The course was initially developed in a collaborative process between the mental health services and Aboriginal people, which involved a National Reference Group consisting of a range of representative stakeholders from the mental health industry, the Aboriginal community controlled sector and the education sector including CSU. The course is delivered by Aboriginal and non-Aboriginal mental health professionals as well as university lecturers.

The Djirruwang Program has aimed to consistently align itself with broader developments in the Aboriginal mental health arenas, and to remain consistent with relevant mental health policy directions and broader health industry policies and initiatives.

Of the program, Brideson & Kanowski have commented that :

If the Aboriginal mental health workforce is allowed to grow into a valued, respected and essential component of the workplace those people occupying the professional positions will provide the cultural context to the workplace. The inclusion of the National Practice Standards into the program has provided a vehicle to establish equivalence as professionals in their own right and to move into 'adulthood' in respect to mental health service delivery.
(Brideson & Kanowski 2004, p7)

OATSIH has provided funding to the CSU to conduct the Djirruwang Aboriginal and Torres Strait Islander Mental Health Program (DATSIMHP) at its Wagga Wagga campus in the 2003 to 2005 academic years, and again in 2007 (CSU self-funded the course in 2006).

Aboriginal Health Worker Training Package

Another key source of training in relation to Indigenous SEWB in the near future will be the Health Training Package recently endorsed by the National Quality Council. One of the two certificate courses relating to Indigenous health is relevant here – the community care stream of Certificate IV in Aboriginal and Torres Strait Islander Health Care. This stream contains units of competencies, including orientation to mental health work as a compulsory unit. A number of electives also cover issues relating to Indigenous SEWB, including 'The Provision of Non-clinical Services for People with Mental Health Issues'. The Health Training Package also includes a community stream of the Diploma in Aboriginal and Torres Strait Islander Health Care.Top of page

1.10.3 Good practice - therapeutic approaches

Literature from Australia and elsewhere suggests that, although understated within mainstream service provision, the role of traditional healing frameworks is highly valued by Indigenous people internationally. Kirmayer et al (2003) states that 'notions of tradition and healing are central to contemporary efforts by Aboriginal peoples to confront the legacy of historical injustices and suffering brought on by the history of colonialism' (p15).

In the Australian context, the importance of Aboriginal healing approaches outlined in the recommendations of the BTH Report, includes a requirement that all services and programs provided for survivors of forcible removal emphasise local Aboriginal healing and wellbeing perspectives (HREOC 1997, p563, Recommendation 33a).

Narrative therapy

The 'narrative approach' has been identified by Aboriginal people in a variety of contexts as offering the possibility of culturally sensitive and appropriate counselling practices. This is said to be because it 'starts from the premise that the job of the counsellor is to help people identify what they want in their own lives, and to reconnect with their own knowledges and strengths' (AHCSA 1995, p18). The narrative approach also asks questions that bring forth the history of problematic truths – 'exploring the history of a person's ways of being and thinking creates the opportunity for that person to identify the real effects of these ways of being and thinking on their life' (AHCSA 1995, p19).

Although the narrative approach has been put forward as a culturally appropriate and sensitive practice, there does not appear to be a widely accepted resource to guide practitioners who may wish to use this approach. There were a few isolated examples of resources relating to narrative therapy in the literature, however these were largely descriptive in nature.

A leading example of the narrative approach being used successfully is the Camp Coorong project in SA. This initiative responded to the needs of families and communities affected by Aboriginal deaths in custody. It provided a context for Aboriginal People to express and address their grief in relation to the loss of their loved ones, and to participate in appropriate healing ceremonies. The use of narrative therapy in the project has been documented, and was described as follows:

The project recognised the importance of Aboriginal people taking the primary role in the telling of their stories, and the importance of an exploration of these stories so that their special knowledges and skills relevant to healing processes might be honoured and re-empowered. As well, the project aimed at providing support for Aboriginal people to take further steps to break free of the destructive stories that have been imposed upon them by the dominant non-Aboriginal culture, including many of the ideas of health and wellbeing that are so often imposed by mainstream services.

Narrative therapy offers a way for Aboriginal counsellors to develop practices that are culturally sensitive and appropriate. This model is not fixed or rigid, and will continue to evolve for Aboriginal use in consultation with Aboriginal people.

(AHCSA 1995, p20)

Nunkuwarrin Yunti also offers a diploma in narrative therapy.

Spiritual healing for loss and grief

Wanganeen comments that successful healing should involve:
  • awareness
  • identification and acknowledgment of losses
  • identification and acknowledgement of emotional legacies
  • reclaiming unrecognised emotional losses eg a sense of identity or power, trust, confidence, self-esteem, safety (Wanganeen 2001). Top of page

1.10.4 Culturally appropriate practice for people affected by forcible removal practices

Marumali Program, NSW

The Marumali Program is a five-day model of healing developed by a member of the Stolen Generations. The Program is designed to equip counsellors with the skills they need to aid Aboriginal people who are suffering from grief and trauma as a result of separation. An important aspect of the training is to respect the rights of the survivors of the removal policies and to allow them to control the pace, direction and outcome of their own healing journey. The Program provides a basis for identifying and understanding common symptoms of long-standing trauma and an overview of the healing journey and how it may unfold. It offers clear guidelines about what type of support is required at each stage. It identifies core issues to be addressed and some of the risks associated with each stage (including misdiagnosis issues), suggests appropriate support to minimise the risks, and offers indicators of when the individual is ready to move onto the next stage of healing.

Training provided under the Marumali Healing Model is designed to empower Aboriginal counsellors to take the lead in this area of work. All participants in the counsellor training are required to have had previous formal training or work experience as counsellors (OATSIH 2001, p3).

Marr Mooditj

Marr Mooditj is a training college that conducts education and training of Aboriginal people, to empower them to competently deliver and manage health care and community services programs in a culturally appropriate manner to the Aboriginal community. It aims to develop and provide holistic programs covering cultural and political issues, provide culturally appropriate health and spirituality programs, incorporate Aboriginal perspectives in environmental health and traditional methods and foods, and promote and preserve cultural differences between Aboriginal communities.

Marr Mooditj delivers a range of training programs, including certificates in Aboriginal and/or Torres Strait Islander Primary Health Care, Home and Community Care and diplomas of Aboriginal and/or Torres Strait Islander Primary Health Care, incorporating mental health care elements.

1.10.5 Good practice examples from comparable nations

The Assembly of First Nations identified a number of common strengths among the projects it reviewed in a paper on successful Aboriginal health programs in Canada, the United States and Australia. Specifically, these features are that:
  • projects tend to be tradition-based and value-based
  • interventions focus on the entire family
  • links are made between spirituality and therapy
  • there is an intimate knowledge of the tribal community and a drawing together of traditions
  • projects respond to the needs of the community
  • the community supported healing and recovery (AFN 1997).
In addition, the Canadian organisation AHF has observed a number of approaches to and elements of healing practices for Indigenous peoples across colonised nations. These include:
  • learning about the history of colonisation
  • mourning the losses
  • reconnecting with traditional cultures, values and practices
  • use of culturally sensitive screening and assessment tools to complement holistic and relational worldviews
  • at the community level, culturally appropriate healing interventions are most effective when rooted in local practices, languages and traditions
  • specific strategies are needed to meet the needs of Indigenous people who do not have strong cultural ties (AHF 2006, pp49-51).
However, the AHF warns of the dangers of assuming that healing programs working well in one context can be successfully transported to another social, cultural or political milieu, even within nations. Of the Australian context, Yava-Hamu-Harathunian notes that:
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Too often the easy option is to believe, accept and then practice under the notion that what is good in treatment for some Indigenous groups in Canada or elsewhere will translate as good and effective for Australian Aboriginal clients with diverse often multiple language use, from diverse cultural backgrounds, and from diverse Aboriginal lifestyles.
(Yava-Hamu-Harathunian 2002, p21)

Many communities in Canada have experimented with various forms of 'sentencing circles' for healing and reintegrating offenders who might otherwise be ostracised and handled entirely within the penal system. Other uses of meeting in circles include:
  • talking circles, in which people speak openly and listen to others' stories to begin to become aware of original hurts
  • sharing circles, in which a high degree of trust is established and people express painful emotions
  • healing circles, where people can work through memories of painful experiences
  • spiritual circles, in which people develop trust in their own experiences of spirituality as a source of comfort and guidance (Kirmayer et al 2003, p20).
Kirmayer et al (2003) assert that the social origins of prevailing mental health problems require social solutions. Following from this, they argue that

…although conventional psychiatric practice tends to focus on the isolated individual, the treatment of mental health problems as well as prevention and promotion among Aboriginal peoples must focus on the family and community as the primary locus of injury and the source of restoration and renewal… Mental health promotion with Aboriginal peoples must go beyond the focus on individuals to engage and empower communities.
(Kirmayer et al 2003, p21)

Other lessons to be gleaned from comparable countries are as follows:
  • United States – postcolonial psychologists Duran and Duran have developed a treatment model that involves reconnecting clients with their Native American identity; this improves self-esteem and sense of identity, which are correlated with healthy functioning. An increased awareness of historical factors reduces guilt and internalized oppression.

    Duran and Duran note that the effects of colonisation have been especially severe for American Indian men, and that treatment models that address issues of the destruction of economic and cultural roles, and a deep psychological trauma of identity loss is effective in treating addictions and addressing family violence (AHF 2006, p30).

  • New Zealand - the cultural renaissance in New Zealand among Maori peoples which resulted in a greater awareness of colonialism and its impacts has seen a number of positive developments. Settlement of claims under the Treaty of Waitangi has allowed some tribes to establish social and mental health services. The National Body of Traditional Maori Healers has been established, and traditional healing is now offered in many primary health care settings. This body recognises regional and tribal variations in healing traditions but also works to achieve a collective approach to issues such as professional standards, policy and access to funding. The Ministry of Health has published standards for traditional Maori healing, with support from the National Body of Traditional Maori Healers (AHF 2006, p31).

  • New Zealand - the existence of treaties that are recognised and respected by government and incorporated into government policy provide an environment conducive to the development of healing programs designed, delivered and controlled by Aboriginal people.

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