Better health and ageing for all Australians

Evaluation of the Bringing them home and Indigenous mental health programs

7.2.1 Auspice organisations

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All SEWB RCs, and almost all Link-Up services, are located in Aboriginal community organisations. BTH Counsellors are employed through ACCHSs. State governments may provide additional services through their State health systems.

Generally it is very desirable that the Programs are run by Aboriginal community organisations. As discussed in chapter 5, this is consistent with the two key National Strategic Frameworks (Health and SEWB).

However, it was clear from the consultations that there are both advantages and disadvantages in locating BTH services in ACCHSs. These are discussed below.

Advantages of locating BTH services in ACCHSs

There are a number of important advantages to locating BTH services in ACCHSs. These include:
  • Culturally appropriate service provision.

  • There are readily available systems of management, oversight and infrastructure, including IT systems.

  • ACCHSs have a physical health focus, which enables other workers within the ACCHSs to refer to the BTH services. (For example, one BTH service reported that it receives quite a lot of referrals from the ACCHS dentist, who sees numerous clients with physical trauma or facial injuries.) This also promotes a holistic approach to Aboriginal health incorporating physical and mental health (which as discussed in chapter 5 is regarded as good practice).

  • ACCHSs have strong relationships with and recognition within their local communities, which is of major benefit to BTH Counsellors in generating referrals (often through word of mouth).

  • Often there would be no realistic alternative pre-existing agency in the communities with BTH services which could take on this role, and it would be inefficient to establish new stand-alone services for this purpose.

Disadvantages of locating BTH services in ACCHSs

On the other hand, there are some major disadvantages to locating BTH services in ACCHSs.

By far the greatest disadvantage is that BTH resources are frequently used by ACCHSs (either wholly or in part) for other services and activities. While ACCHSs are doubtless using these resources in response to their perceptions of community need, this has resulted in BTH resources being expended in ways that may not be altogether in keeping with the original intention of the BTH program. It can also lead to a greater burden on Link-Up services.

It was clear from the consultations for this evaluation that many BTH services are delivering general Aboriginal mental health/SEWB services rather than a specific service targeted towards Stolen Generations members. This is connected to various factors including:
  • The understanding of the roles and responsibilities of BTH Counsellors varies a great deal from one ACCHS to another. Some managers do not appear to understand the intended role of BTH Counsellors, with day-to-day activities and position descriptions sometimes reflecting a completely different role. A manager at one metropolitan service took the opportunity to question the evaluation team about what their BTH worker should be properly be doing.

  • The high unmet demand for Aboriginal SEWB services which are generally unavailable through either the ACCHS or elsewhere. The BTH services also perceive that there is a need for them to be responsive to this demand, and not alienate community members by turning away people seeking SEWB services. (This is an important and sensitive issue for any Aboriginal service). Consistently, the National Strategic Framework - SEWB notes that ‘the demand for programs to meet the mental health and SEWB needs of clients is growing, in part through the awareness of available services and because clients feel more comfortable to seek assistance’ (Social Health Reference Group 2004, p29).

  • The majority of BTH Counsellors do not have formal qualifications in counselling or psychology, and therefore are not best equipped to be providing a counselling service. They often therefore provide more generic support services to BTH clients rather than mental health/SEWB services. This issue is discussed further in chapter 8.

  • The difficulties BTH services reportedly experience in identifying whether a new or potential client is a Stolen Generations member. As noted in chapter 6, it was reported that clients generally do not present initially as needing assistance because of their ‘Stolen Generations issues’ or immediately volunteer this history. It was noted that new or potential clients’ Stolen Generations history, and its connection to their presenting problems, may only become apparent after the service has started work with the client. This may be due to clients’ reluctance to disclose this history (due to perceived stigma), and the fact that clients do not necessarily see the connection between their Stolen Generations history and their immediate presenting problems such as substance abuse or parenting difficulties.Top of page
It should be noted that many of the above issues (lack of understanding of roles, limited formal staff qualifications in counselling or psychology etc) are not unique to ACCHSs or Aboriginal services, but are also true of mainstream health services also.

Other ways in which BTH resources are being used by ACCHSs for activities other than that intended include that:
  • Some ACCHSs are taking quite large percentages of the BTH funds to cover overheads – in some instances up to a half. OATSIH provides a lump sum to cover all expenses associated with each BTH Counsellor costs (this issue is discussed further in Chapter 8). In one particularly extreme example, an ACCHS does not have a BTH worker at all, and uses all of the allocated BTH funds for other ACCHS activities; BTH workers from another service regularly visit that ACCHS to provide services.

  • Some BTH staff also have formal or informal responsibilities to contribute to other programs eg the Program Manager managing other programs as well as the BTH Program, filling in for other staff on the ACCHS mental health team when they are unavailable, or a male BTH Counsellor being referred Aboriginal male clients (who have not identified as Stolen Generations members) from the ACCHS mental health team so that a gender-specific service can be provided.
Other disadvantages of locating BTH services in ACCHSs include that:
  • Some of these services have experienced governance and/or management problems, which can have a negative impact on the BTH program, other community organisations and the community more broadly. This in turn can affect the ability of BTH Counsellors to forge strong relationships within the community and to develop trust with their clients.

  • Some Stolen Generations members, particularly first generation members, may not be comfortable accessing mental health support through ACCHSs, particularly given the stigma sometimes associated with mental health services (as discussed in chapter 6). This raises the need for additional support services to be available outside the health service context (such as through Link-Ups or on an outreach basis).

  • There can be concerns about confidentiality and privacy for some clients in accessing services in an ACCHS given it is such a well-known organisation visited by many community members. This makes the precise physical location of the BTH service particularly critical to encourage more first generation Stolen Generations members to attend the services (discussed further below in this chapter).Top of page

The nature of the premises and physical location of services

The consultations indicated that the nature of the premises and precise physical location of services, particularly BTH services, is a critical factor which can either encourage or discourage Aboriginal people coming to the service.

It is preferable that both Link-Up and BTH services are located in premises which are: convenient to get to (including by public transport); in premises with a community (versus, for example, ‘clinical’) feel; and are not near places with negative associations for Aboriginal people.

It is also critical that BTH services are in locations and offices which do not compromise confidentiality. For example, one service is located opposite the courthouse and near the police station and child welfare department. While the staff felt this was a good location since they often came across many Aboriginal people in the vicinity, Aboriginal clients and stakeholders generally felt it was undesirable due to confidentiality concerns and the negative associations of those buildings.

Similarly it is important that the actual rooms available for the BTH Counsellors are completely confidential – eg for the use of the BTH Counsellor alone and not other staff, sound-proof, and not easily visible to passers-by.

In relation to BTH services, it is also important to consider exactly where the BTH service is located within the ACCHS in terms of protecting confidentiality. For example one way to do this is to house BTH workers outside but adjacent to the main ACCHS complex, with a separate entrance, as is the case with some of the BTH services such as in Katherine and Cairns. This means that clients do not have to go into the main ACCHS reception, where they may be seen by various other community members. This was generally regarded as a good idea, although a few of those consulted felt that this in itself could compromise confidentiality if it was then very visible and obvious that clients were going to the BTH service (rather than just attending the ACCHS, which may be for a physical health problem).

The Taree BTH service (Biripi) illustrates a number of the above principles. It is housed in a building across the road from the ACCHS, which is shaped like a boomerang. The building is decorated in soft healing colours (lilac, apricot), and the shape of the building means that the BTH and Drug and Alcohol Counselling rooms cannot be easily viewed by people walking past through the corridor, therefore providing more confidential and peaceful surroundings. Aboriginal staff and external stakeholders reported that these design aspects have improved SEWB outcomes for BTH clients, as clients appear more relaxed about speaking to specialist staff and more likely to stay for the duration of their consultation than was the case prior to the new premises being built.
GPP2:
Link-Up, BTH and SEWB RC services should be located in Aboriginal community controlled organisations. Link-Up and BTH services should be located in premises which: provide confidentiality (both in terms of access to the service and within the service); are convenient to access, including by public transport; have a ‘community’ rather than ‘clinical’ feel; and are not near places with negative associations for Aboriginal people.
In terms of the above principles, the BTH services vary in how ideal their locations are but most are located reasonably well. Where BTH services are in less than ideal premises, the limitations are around issues such as accessibility to public transport, confidentiality of access to the service, and unavailability of appropriate counselling rooms. In practice there is often little choice about where the service is located, or what space is available to house the program, given that the ACCHSs were in pre-existing premises before the BTH Program was implemented. The consultations also indicated that, particularly in smaller or more regional/remote locations, there may be limited choices available; for example, some of the services which have recently moved have not been able to secure ideal premises.
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