Evaluation of the Bringing them home and Indigenous mental health programs

1.9 Provision of mental health services to Aboriginal Australians

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The literature indicates that mainstream mental health responses to Aboriginal people are often inadequate, and that the Aboriginal mental health workforce suffers from shortages and an under-valuing of workers. These issues are discussed in more detail below.

1.9.1 Limitations on the provision of culturally appropriate mental health services

The seminal Ways Forward report identifies that Aboriginal concepts of mental health are holistic and are defined as follows:

Health does not just mean the physical wellbeing 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 the cyclical concept of life-death-life.
(Swan & Raphael 1989)

The findings from Ways Forward indicated that:

Aboriginal people perceived mainstream mental health services as failing them, both in terms of cultural understanding and response, and repeatedly identified the need for Aboriginal mental health services which took into account their concepts of the holistic value of health and their spiritual and cultural beliefs, as well as the contexts of their lives.
(Swan & Raphael 1989)

More current literature on Aboriginal mental health suggests that the mental health of Aboriginal peoples has largely been neglected in Australia, and that mental health has only recently been identified as a policy priority (Vicary & Bishop 2005; AIHW 1998). It also suggests that mental health approaches for Aboriginal Australians continue to be inappropriate and inadequate, and that Aboriginal people are 'less likely to engage in mental health services, [and] are also more likely to engage at a more chronic level, and for shorter periods of time' (McKendrick & Thorpe 1994; Vicary 2002).

Vicary & Bishop (2005) assert that the difficulty many Aboriginal people have in talking to mental health professionals is due to 'stigma, cultural misunderstanding, involuntary confinement, and the failure of past mental health approaches' (p8). Other authors have pointed to the cultural inappropriateness of existing services, and the failure of mental health services and clinicians to embrace Aboriginal conceptualisations of health and wellbeing (Westerman 2004; Dudgeon 2000; Garvey 2000). Yet others have argued that the failure of mental health services to respond to the mental health needs of Aboriginal Australians is due to the lack of national data measuring the impact of loss, separation and traumatic experiences upon the Aboriginal population, and the nature of trauma, grief and loss and their impact upon the physical and mental health of Aboriginal people (Vicary & Bishop 2005, p9).

In addition, it is suggested that the notion of SEWB is still not well understood by mental health practitioners in Australia (Emden et al 2005). SEWB is described as touching on all aspects of life, including social and emotional factors as well as economic and physical factors. Vicary & Bishop have identified a number of determinants of 'wellness' in the Aboriginal concept of wellbeing, which may include (but are not restricted to) employment status, substance abuse, family violence, dispossession, effects of the Stolen Generations, cultural identity, and housing and financial problems (2005, p11). Emden et al have also identified a range of issues that can impact on SEWB including:
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• grief for family members who have died through suicide, overdose, violence, accident or ill health
• anger at past and continuing injustices towards Aboriginal people by the non- Aboriginal population of Australia, including incarceration issues
• feeling overburdened and overwhelmed by constant carer responsibilities
• chronic poverty, sub-standard living arrangements, inadequate transport, malnutrition and poor physical health leading to chronic feelings of hopelessness, inadequacy and powerlessness
• confusion and unhappiness over Stolen Generations family members
• disputes and tensions between family and community members concerning marriage breakdowns, children's misbehaviour, unemployment, lack of money, inter-community conflicts and rivalries (2005, pp83-84).

Literature from other comparable colonised nations such as Canada, the US, New Zealand and Greenland suggests that Western medical practitioners are generally challenged by holistic healing practices encompassing the mental, physical, emotional and spiritual aspects of the individual as well as families, communities and the physical environment. Further, a holistic approach also challenges many practitioners who separate physical and mental health and do not deal with the spiritual dimension. Such approaches also challenge governments that compartmentalise funding through departments such as health, education and housing, which are natural to Aboriginal service providers (AHF 2006, p51).

It is also important to note that the inadequate emphasis on Aboriginal SEWB issues in Australian mental health service delivery is part of a broader problem within that system: that the bulk of mental health resources are targeted towards acute care and the treatment of mental illness through hospital-based services (Senate Select Committee on Mental Health 2006, pp151-182).

1.9.2 Workforce issues

Connected to problems with mental health service provision to Aboriginal Australians are workforce issues. The Royal Australian College of General Practitioners (RACGP) observes that there are mental health workforce shortages for Aboriginal communities and remote communities in particular - 'rural health continues to be out of sight, out of mind and out of funding. Remote Aboriginal communities encounter this doubly' (RACGP 2005, p8). This finding was reinforced by the recent Senate Select Committee on Mental Health (2006, pp445-8, 452-456). In SA it has been similarly observed that

services for Aboriginal Australians continue to be acutely under-funded, struggling to meet basic needs… Workforce development for Aboriginal health workers in mental health is much needed, as well as these workers being able to easily access specialist support.
(SADGP 2005, p8) Top of page

As well as workforce shortages, the literature points to the under-valuing of the Aboriginal mental health workforce. Brideson (2004) characterises this workforce in Australia as being subject to 'Seasonal Work Syndrome', in which workers are akin to seasonal workers or labourers. Aboriginal mental health workers are frequently responsible for limited tasks and specific roles (often repetitive) in the workplace that are generally viewed by others as being much less important, and/or made to feel that their role is much less important than other 'real professions' (Brideson 2004, p2). Aboriginal mental health workers may also experience limited recognition of their role, frustration in the workplace, increased stress levels, limited opportunities for training and a lack of systematic career development and professional opportunities (Brideson 2005, p8).

Similarly, the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2002) has acknowledged that there is 'a general sense of frustration with the lack of recognition of the value and skills of Aboriginal mental health workers by other professionals and managers in health services' (RANZCP 2002, p1).

The RANZCP has also devised a position statement which recognises:

• the complexity of mental illness in Aboriginal mental health and the need for an understanding of a range of cultural, historical, family and societal issues
• the relationship between Aboriginal mental health workers and their clients often extends outside the normal clinical experience of the patient-therapist relationship
• the nature of the work of Aboriginal mental health workers is often demanding, being outside the normal time and geographical boundaries of the work of other mental health workers
• mature Aboriginal people with no formal educational qualifications may possess a unique knowledge and particular skill in dealing with mental health issues within their local community
• cultural awareness courses are a valuable tool for any service dealing with Aboriginal people, and should be credited as part of any workers' continuing education
• resource allocation should reflect the standards expected by any other mental health workers, for example in terms of staffing levels, appropriate resources to enable them to do their work effectively, and occupational health and safety requirements (RANZCP 2002).

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