Evaluation of the NT MOS projects
D: Literature review
Up to Closing the Gap: Northern Territory
Table of contents
Attachment - Literature review
Improve government service provision to Aboriginal people
Take language and "world view" seriously
Effective and ongoing consultation and engagement
Local focus and recognition of diversity
Community based and community owned initiatives
Recognition and respect of Aboriginal law and empowerment and respect of Aboriginal people
Balanced gender and family, social or skin group representation
Adequate and ongoing support and resources
Ongoing monitoring and evaluation
"Prevention is better than cure" - community education
References
Attachment - Literature review
The purpose of this literature review is to identify evidence based good practice approaches in providing counselling and support services for Aboriginal children and young people suffering trauma resulting from any form of child abuse or neglect, including sexual assault, in remote communities.Much of the research literature on the health and wellbeing of Aboriginal children and young people looks at the historical, social and environmental reasons which contribute to the incidence of abuse and neglect of Aboriginal children. This can be summarised by the following quotation from the Report of the Northern Territory Board of Inquiry Into the Protection of Aboriginal Children from Sexual Abuse, Ampe Akelyernemane Meke Mekarle "Little Children are Sacred":
...that the incidence of child sexual abuse, whether in Aboriginal or so called mainstream communities, is often directly related to other breakdowns in society. Put simply, the cumulative effects of poor health, alcohol, drug abuse, gambling, pornography, unemployment, poor education and housing, and general disempowerment lead inexorably to family and other violence and then on to the sexual abuse of men and women and, finally, of children.
(Board of Inquiry Into the Protection of Aboriginal Children from Sexual Abuse, 2007, p.6)
The reasons why child abuse may occur will not be discussed in any detail in this literature review. Rather, the focus of this review is to identify what the literature indicates are good practice approaches, or what is effective, in addressing the needs of Aboriginal children, particularly those in remote communities where, as the literature researched reiterates, there is an identified need for counselling and support services as well as particular challenges to service delivery.
The literature reviewed finds that there is little specific research literature on what are effective and culturally safe approaches to programs which attempt to prevent or address child abuse or neglect. (Stanley et al,2003; O'Brien, 2010) so there is little documented evidence based practice to learn and develop effective practice from. Literature agrees that more evaluation (and more inclusion of Aboriginal perspectives in the evaluation process) is necessary for this to develop.
There are however common themes in research literature about what constitutes good practice in the provision of services to Aboriginal children and families. The Ampe Akelyermemane Meke Mekarle "Little Children are Sacred" report makes specific recommendations for governments on addressing the issue of child abuse in Aboriginal communities, and central to these is the commitment to genuine consultation with Aboriginal people. The Inquiry puts forward nine guiding principles or ‚rules of engagement. for governments to adopt in dealing with Aboriginal people to help ensure that ethical reform occurs. For the purposes of organising this review, we have used these guiding principles as subheadings under which discussion based on research literature is presented.
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Improve government service provision to Aboriginal people
A consistent theme in the research literature is that there is a lack of appropriate abuse counselling services for Aboriginal children and culturally appropriate support services for families, and that this is particularly true in remote areas.Discussion regarding "improving government service provision" in the literature is both about improving access to services which, as noted above, is particularly necessary for remote areas and comes with its own set of logistical difficulties. It is also about improving the way Federal, State and local governments work together through better cooperation and coordination to improve the way in which services are provided and quality of services.
There are logistical difficulties which impact on the ability to provide services to Aboriginal communities in remote areas and are not easily addressed. A major issue for services in remote communities is attracting and retaining appropriately qualified staff (this is discussed in more detail under the other principles of engagement), difficulties of access due to transport and weather restrictions, and "sorry" business which restricts activities.
Literature talks about taking a holistic approach to addressing the health and wellbeing needs of Aboriginal people. Evidence regarding the social determinants of Indigenous health suggests that evidence based approaches need to take a broad view of the social determinants of health and recognise the underlying as well as the immediate causes of ill health (Carson, et al, 2007). Some literature notes that children presenting with inappropriate sexualised behaviours are likely to have experienced childhood trauma and a range of other factors, and recommends integrated services as well as specialised therapeutic services (O'Brien, 2010; Purdie, et al, 2010). Literature also notes that Aboriginal clients often need practical assistance to meet their basic needs and are unable to prioritise intervention services if these basic immediate needs cannot be met (Fan, 2007; Flaxman et al, 2009). Services which are able to provide assistance or referrals to meet these needs are more likely to gain the trust of clients.
As remote communities often have very limited access to appropriate services for the health and wellbeing of children and young people, better coordination between agencies and services through sharing of information, resources and training and taking a 'team work' approach to client case management can help ensure that a more holistic approach is taken to address the client's therapeutic and other needs. Case management approaches can be effective in reducing service duplication of service, misunderstandings and in making appropriate referrals (including for meeting basic needs). Case management approaches are advocated to reduce the need for a client, particularly if they are a child or young person having to re-tell a traumatic or sensitive story repeatedly (Cripps in Purdie, et al, 2010), especially where cultural reticence about talking about sexual matters exists. Case management approaches can also help ensure that client follow up occurs. Literature notes that there are issues with notification of child abuse where it seems like interventions are being made which are about keeping the child safe, but follow up counselling is not provided / is not available for the victim (Coorey, 2001). Minimising the risk of the victims developing sexually inappropriate behaviour, or the risk of other offending behaviour, through providing therapeutic counselling for victims by appropriately qualified services is seen by some research literature (O'Brien, 2010; Purdie, et al, 2010) as part of the solution to preventative approach to intergenerational abuse and other criminal risk factors, as well as ongoing health and wellbeing repercussions .
Improving government service provision through increased cooperation and coordination between agencies (moving away from the 'silo' approach), can also create multiple entry points to services and increase community access to and engagement with services. Better coordination between agencies is seen as an important way of ensuring that there are multiple entry points to both Aboriginal only and culturally appropriate mainstream services and increasing access to services. While literature suggests that Aboriginal people prefer to access Aboriginal services, particularly in regional and remote communities, there can be issues within the community which prevent this from occurring. Multiple entry points can help ensure that children and young people do not fall through 'the gap' in service provision.
Improving government service provision means adequate resources. Literature reviewed agreed that a three to four year funding cycle is not sufficient to provide the services required. Governments need to make long term funding commitments to programs which have realistic outcomes, ie not tie program funding to short term outcomes which are often unrealistic given the nature of the program (Santhanam, 2005; BIPACSA, 2007). This will be discussed more fully under ‚Ongoing monitoring and evaluation..
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Take language and "world view" seriously
The need for "culturally appropriate" or "culturally safe" programs or responses is a key theme in literature reviewed.Literature reviewed notes that services provided to Aboriginal children and families need to be "culturally appropriate" or "culturally safe" which essentially means they need to take into account and/ or be respectful of the cultural practices of the particular Aboriginal community the services are for. Services should provide cultural awareness training for staff to educate them about the different cultural and linguistic groups within the service area and about culturally appropriate behaviour. The Australian Health Ministers Advisory Council has developed the national Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004-2009, which provides guidance to health services and practitioners on this issue.
Although ideally women staff should work with women and male staff should work with men, due to the lack of appropriately qualified and experienced staff available to work in remote areas, this is not always possible and is particularly problematic because of the concepts of "shame" associated with sexual abuse.
The NT Board of Inquiry also notes the need for cross-cultural awareness training, as there is often not only a poor understanding of local Aboriginal culture by non- Indigenous workers, there can often be a poor understanding of what is socially acceptable in mainstream Australian culture by Aboriginal children and families (due to the influence of violent TV, movies, pornography, drugs and alcohol).
There are also language barriers, particularly in remote areas, where English may be a third or fourth language. Flaxman et al (2009) notes that people in remote communities would prefer support workers to speak "in language" where possible. While some knowledge of language would assist in gaining trust in the community and assist with communication, language barriers between Aboriginal clients and non- Indigenous workers can also be assisted by either using a translator (which may be problematic for privacy reasons), or by using very plain and simple English.
Effective and ongoing consultation and engagement
Research literature is clear that effective and ongoing consultation and engagement with Aboriginal communities is essential for the effectiveness of the program. It is equally clear that this process takes time and patience.Literature identifies the two main barriers for Aboriginal children and families in remote settings receiving appropriate support services: services unavailable or difficult to access; or lack of engagement, where services are not utilised because they are not appropriate for the needs of the community or the community is uncomfortable with the provider. Services which fail to engage the community have low participation rates and are therefore not effectively delivering services.
Engaging the community effectively can ensure the Aboriginal community have ownership of the solutions to their problems (Coorey, 2001; Stanley et al 2003; BIPACSA, 2007; Carson, et al, 2007). This is seen as important in terms of moving away from a paternalistic 'top down' imposed approach to one which can empower the Aboriginal community, and ensure the sustainability of the program, particularly if there is adequate support and resources for this to happen. Providing feedback about program outcomes is an important means of keeping the community engaged as well as capacity building.
Literature suggests that engaging the community begins with establishing a respectful relationship and developing trust. This is necessary to overcome any distrust of government or historical reticence to use health services due to child removal policies in the past. In their chapter on "Trauma, Transgenerational Transfer and Effects on Community Wellbeing", Atkinson et al point out that the "default perception of a new service provider in most communities is more likely to be mistrust over ambivalence, especially if the service provider is non-Indigenous and comes with new ideas, new plans and an inability to learn from a new environment" (in Purdie, et al 2010, p.140). In this context, community mistrust may be a particular issue for services dealing with the sensitive issue of child abuse.
Literature researched suggests a range of ways to appropriately engage the community:
make contacts use Aboriginal and non-government or community organisations for liaison; meet where people feel comfortable; use interpreters; get introductions; learn the language; use other contacts; build mutual respect through honesty and openness; share some personal information to allow trust to develop; demonstrate willingness to listen; demonstrate cultural competence; demonstrate sincerity; involve community Elders and the wider Aboriginal community; learn from the community both from their ways of doing things and from what they have seen other service providers do in the past; and allow time for this (do things in "local time").
The NT inquiry suggests that additional time to build trust and respect may be necessary in remote Aboriginal communities because people's initial responses tend to be "either what they think the mainstream culture wants them to say or what they think the mainstream culture wants" (BIPACSA, 2010, p 52).
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In their "themed study" undertaken as part of the national evaluation of the Stronger Families and Communities Strategy 2004-2009, Flaxman et al found that involving service providers, Aboriginal Elders and service users in the planning, implementation and sustainability stages of the Communities for Children program was "beneficial, not only in increasing people's awareness of programs, but also in designing and developing programs appropriate to community needs" (Flaxman, et al 2009, p. 7). It should be noted that this process was more successful in urban and regional areas where people were available and easy to contact. The four year funding model for this program did not allow sufficient time and resources to consult adequately with Aboriginal communities in remote and regional areas.
Conversely, Flaxman et al also found that this participation in this program was adversely effected by the Federal Government's Northern Territory Emergency Response (NTER), despite it having a community development approach (as opposed to the 'top down' approach of the NTER). Both interventions were perceived as "the authorities" or "government representatives". "Many community members were sceptical of service providers' sincerity after the intervention began, which made it difficult to build and maintain community trust". (Flaxman et al, 2009 p.37)
Aboriginal communities are diverse and made up of different language groups, and different family and clan groups. Literature notes that there may be feuding between families or clans, or there may be protocols which mean members of one clan will not speak in front of another, or there may be a dominant family in the community with a greater control of resources. In order to effectively engage the whole community, the views of all groups need to be taken into account. This type of consultation process is lengthy and time consuming, but time and developing trust within the community is integral to whether a service is appropriately developed and used. (Flaxman et al, 2009; Santhanam, 2005; Purdie et al (eds) 2010)
That an invitation has been extended by a community does not guarantee that everyone in the community will welcome or support the change process. There are likely to be individuals who prefer the status quo because of their vested interests in certain behaviours or situations, their inability to appreciate that there is a better way of living, or from their experience of previous programs that were abandoned or failed to achieve their promised outcomes. Consider the following advice: 'If a community is not vocal about changing their own circumstances and you cannot easily identify any natural leaders don't waste your time. If the community is using lots of gunja [marijuana] it is even more useless to attempt change' (personal communication, Komla Tsey, 2008).
(Atkinson, J. et al in Purdie, N. et al 2010)
In their paper on child abuse and neglect in Indigenous Australian communities, Stanley et al (2003) note that Aboriginal children and young people do not appear to have a "voice" in discussion of these issues and possible solutions. Given that Aboriginal children and young people are the target group for services providing counselling on trauma, it would seem appropriate to seek their views as part of the community consultation process.
Literature reviewed notes that having pre existing contacts within the community is the most effective way for non-Indigenous providers to engage the community by providing introductions and referrals. While people from within the community have a distinct advantage in engaging the community in programs because of the pre-existing local knowledge, connections and trusting relationships, literature notes that there can be benefits in having 'outsiders' involved in service provision. Literature notes that when people from outside the community have been able to establish a trusting relationship with the community, are 'known' and provide culturally appropriate services, they may be the preferred service provider because they are not part of the family or clan system and can therefore be impartial (Coorie, 2001; Flaxman et al, 2009; Westerman, 2004; Purdie et al 2010).
As noted previously, program and services provided to Aboriginal children and their families need to be flexible both in design, so that they meet the needs of the local community, and in the way services are provided.
How the service is provided can impact on how effectively it is utilised. Some of the literature suggests that services providing counselling to Aboriginal children and their families on the trauma of child abuse should be located in multi-function centres or hospitals to give privacy to clients; other literature suggests that services which require clients to travel to access them creates a barrier because of transport costs, difficulties with travel in the wet season, and child care arrangements for mothers with multiple children to look after. Some literature points to service delivery which is non-threatening and informal and able to be provided away from formal institutional settings, such through mobile services or making home visits, as being means which facilitate service usage. Ensuring that the service is confidential and that the privacy of the client is respected is important because there is often cultural reticence to talk about sexual issues and associated feelings of 'shame'.
Having multiple entry points to a service can be useful, some health services for Aboriginal children and young people find close linkages with other services an effective way to engage clients. For instance, through home visits the infant and maternal health care nurse in able to develop relationships within the community and make referrals for support. Cooperation, collaboration and networking with other agencies and service providers (mainstream and Aboriginal) can increase sharing of information and resources and contribute to a more holistic approach being taken to the meet the therapeutic and practical needs of the community. Referrals from other members of the community, or other trusted service providers are essential in building trust in the community. Coorey (2001) notes that any service provider (Aboriginal or non-Indigenous) needs to be providing a quality service for Aboriginal women, otherwise they will not take their children there for counselling and support.
Research literature notes that there are many challenges for service providers in establishing and maintaining ongoing engagement with Aboriginal clients in remote communities, but also makes clear that developing and maintaining respectful relationships is a key component to the effectiveness of a program.
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Local focus and recognition of diversity
The Aboriginal population is made up of culturally diverse groups. Communities are made up of different language groups, and different families and clans. Literature reviewed indicates that, if generic programs are used, they need to be adapted to the needs of the local community, and they need to have the flexibility so that they are able to be adapted.Again, this emphasises the importance of genuine consultation with the community.
Community based and community owned initiatives
The NT Board of Inquiry argues that well resourced programs that are owned and run by the community are more successful than generic short term programs implemented with little community consultation and further "that many Aboriginal people perceived that present government policy tended to focus more on government control than on supporting community-owned initiatives". (BIPACSA , 2010, p. 53).As discussed previously, engaging the local Aboriginal community effectively can encourage them to have ownership of the initiative (Coorey, 2001; Stanley et al 2003; BIPACSA, 2007; Carson, et al, 2007). Services which are able to build community capacity are seen as particularly important in terms of contributing to self determination.
Research literature supports the view that Aboriginal community control can contribute to the effectiveness of a health intervention, as does having clearly defined goals that meet community needs.
Literature reviewed agrees that counselling and support services for children and young people should be community based. O'Brien (2010) finds that most clinicians working with children belief that therapeutic counselling needs to be ecologically based (ie in the local context) for it to be effective and other literature notes that Aboriginal people are more likely to use services where the provider has a presence in the community, even if it is a non-Indigenous worker providing a culturally appropriate mainstream outreach service (Westerman, 2004).
There are practical difficulties involved in providing community based services for remote settings – the main one being in the shortage of suitably qualified and experienced practitioners willing to work in remote communities. Sandthanam (2005) notes that remote area work "...needs a unique set of skills. The sensitivity and expertise needed to do community development and integrated interventions are not part of mainstream university training" (Sandthanam, 2005 p.10). Non-indigenous workers often find remote area work challenging and are not trained in dealing with the kinds of issues they face in remote Aboriginal communities. Aboriginal workers are often not adequately trained to deal with the sensitive issue of child abuse. Recruitment and retention of appropriately qualified staff will be discussed further under "Adequate and ongoing support and resources".
As noted by Cripps (in Purdie et al (eds) 2010) and in Carson et al (2007), there is not a lot of documented information about health and wellbeing services run by Aboriginal organisations in Aboriginal communities in the health and academic literature, which means there is limited opportunity to learn from programs which are regarded as successful and worthwhile by Aboriginal communities.
While most of the research literature agrees that Aboriginal communities would prefer to use services provided by Aboriginal workers, there are some reservations about Aboriginal community controlled family services (Coorey, 2001; Flaxman et al, 2009) as these are sometimes seen as being owned and run by one family within the community. For counselling and support services particularly privacy can be a concern. In remote communities especially, some literature suggests that when non-Indigenous providers have gained community trust, a non-Indigenous worker may be preferred for these reasons. Wherever possible, Aboriginal clients should be offered the choice of an Aboriginal or non-Indigenous worker.
Literature suggests that, for an intervention to be effective, there must be good governance practices and social accountability; clearly defined management structures (Carson, et al eds, 2007). Ensuring that a service is professional and has good governance practices can also alleviate some of the concerns relating to community owned and run initiatives regarding preferential treatment or divided loyalties within the local community.
Coorey (2001) notes that there are specific issues which can impact on communities using sexual assault services in remote locations and suggests location in a multifunction centre can help alleviate fears about privacy and confidentiality. In small communities, local Aboriginal workers can experience additional stresses where both the offender and victim are known to them, particularly with regard to notifications of child abuse. There may also be fear of reprisal. The literature is very clear about the need for adequate training, support and supervision for support workers, especially for 'solo' workers and local Aboriginal workers who face additional pressures.
some [workers] described instances where family members had made inappropriate requests, asking Indigenous service provider workers to borrow vehicles and equipment for personal use. In these situations, it was often easier for Indigenous workers to blame the non-Indigenous supervisors for their inability to give preferential treatment or share resources, than to refuse family members requests themselves.
(Flaxman et al, 2009 p. 31)
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Services to remote communities are most often provided as outreach or mobile services. Literature reviewed has mixed views about the 'fly in/ fly out' model because the service it provides is often unreliable (due to difficulties in attracting and retaining workers, the large areas serviced and transport issues, particularly in the wet season). However, given the need for remote communities to be able to access services, it is preferable option to not having services available.
Percieved problems with the 'fly in/ fly out' model are:
- Insufficient time to build trust between the worker and the client, particularly when the worker is non-Indigenous
- The culture divide (especially when the worker is non-Indigenous) as services from the city are 'alien'
- Lack of continuity of workers
- Unreliable service when positions are unable to be filled
- Follow up is necessary but not often done in remote areas because of time commitments of workers
- The community knows who is flying in, so there is no privacy
- Misses out on clients who fail to attend appointments or don't make appointment times, and those that prefer to 'drop in'
- Support is not available in a timely way if services are infrequent
- Services are not available in the wet season or during "sorry" business as there is no community access.
In the case of the remote area child and youth mental health services, (Santhanam,2005) establishing an arrangement with the Flying Doctor service meant that workers were able to increase the frequency of visits to remote settings, which had the effect of increasing community engagement with the service. Increasing the number of workers meant that a smaller number of communities were allocated to each worker, which enabled them to provide the services more regularly. It also created a team which meant that workers were able to support each other and work collaboratively.
Santhanam (2005) notes that having an Aboriginal worker as part of the 'fly in/ fly out' team was seen as a critical factor for providing a user friendly practice, and helped to engage the community. In cases where an Aboriginal support worker in the service was not available, working with an Aboriginal worker from a different stream (such as a youth worker or Bringing Them Home Counsellor) was found to be useful and effective.
The 'fly in/ fly out' model works most effectively if it is supported by a locally based Aboriginal support worker in the community, who can provide appropriate ongoing support to clients and do community development work. The locally based Aboriginal support worker also provides support to the (usually non- Indigenous) specialist who would fly in and out (Santhanam, 2005).
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Recognition and respect of Aboriginal law and empowerment and respect of Aboriginal people
The inquiry notes that such recognition is important, but also that it is not in a position to provide a comprehensive outline on how Aboriginal law should be recognised in relation to mainstream Australian law.This was not a key issue in other literature reviewed, although cross cultural education was. Non- indigenous service providers do not always have a good understanding of Aboriginal law. Some Aboriginal people have also lost touch with traditional Aboriginal law and do not have an understanding of mainstream Australian law. Child abuse, and sexual abuse is not acceptable in either traditional Aboriginal law or in mainstream Australian law.
Balanced gender and family, social or skin group representation
Aboriginal communities are not homogenous. They are made up of different language and skin groups, and of different family and clan groups. In order to engage the community effectively, service providers need to have an understanding of the different groups within the local community and involve representatives from all groups. For cultural reasons some groups will not discuss particular issues in front of other groups, and there will also be different power groupings within these groups. As the research literature notes, genuine consultation which seeks the input of the diverse groups within a community can be time consuming.Loyalties and rivalries between clans can cause conflicts of interest for Aboriginal workers who are from the local community. It could also be a barrier to accessing the service for some members of the community.
Adequate and ongoing support and resources
Adequate and ongoing support and resources is a key theme in the literature reviewed.The three or four year funding cycle does not allow sufficient time to engage the Aboriginal community, develop trust and respect and deliver services which impact on the community. In their "themed study" as part of the national evaluation of the Stronger Families Stronger Communities Strategy, Flaxman et al noted that "[O]ne respondent in a regional centre reported that it had taken six years to establish a rapport with the community: another reported that it had taken three years (since the establishment of [the program]). (Flaxman et al 2009, p. 27).
Ongoing cycles of pilot programs or programs which are promising but are not resourced to continue mean that it is harder to engage the community in the next new program. Literature suggests that longer term funding demonstrates an ongoing commitment to the program and can help build community confidence about participating in it. Literature also suggests the consistency and sustainability of services are more important for Aboriginal service uses than for non-Indigenous users, because "we have had a 20-year history of six-month programs" (BIPACSA, 2007, p55). Some literature suggests that short term interventions with no sustained follow up could be more detrimental to children and communities than no intervention at all (Flaxman et al, 2009; O'Brien, 2010).
It is difficult for services without longer term funding to demonstrate their commitment to improving outcomes in Aboriginal communities and uncertainty around continued funding impacts on their ability to recruit, support and retain appropriately qualified workers. Literature notes that providing services in remote locations is expensive.
Recruitment and retention of staff is a major challenge to providing services in remote Aboriginal communities. Workers in remote areas face challenging conditions, including limited suitable accommodation, working long hours with little support, and having to be self reliant. Literature notes that remote work is often done by people who may be qualified to deliver the services but have little experience of the reality of remote work, or lesser qualified or graduate staff with potential, rather than those with specialised experience (Santhanam, 2005; O'Brien, 2010). Staff providing counselling and support services to Aboriginal children and young people report that they are often working beyond their capacity, which leads to burn out and attrition, and this effects the service provided to communities.
Literature researched notes that the area of Aboriginal child abuse and neglect is sensitive and requires specialist treatment. O'Brien (2010) and Hunter (2007) note that there is no national scheme or qualifications in this area, and advocate for minimum requirements. Currently therapeutic counselling to children with sexualised behaviours could be provided by social workers, psychiatrists, psychologists or experienced (but unqualified) counsellors. These workers may or may not have had specialist training in working with children. Having a national accrediting body could lead to more evidence based practice in treatments.
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O'Brien (2010) also notes that Aboriginal children are overrepresented in the child protection system and that there is a shortage of culturally appropriate interventions for Aboriginal children, young people and their families in the agencies expected to work with them. While the research literature indicates that most Aboriginal people would prefer to use services provided by an Aboriginal worker, there are insufficient Aboriginal workers with the appropriate skills and qualifications in this field, and that this needs to be addressed through improved educational and training opportunities.
While adequate supervision and support is important for all workers, it is particularly important for 'lone' workers in remote settings. Training and support, particularly through mentoring can help build the capacity of workers and increase staff retention. Literature notes that non-Indigenous workers need adequate training and support to be able to deal with the demands of working in remote communities and in cultural competence and that Aboriginal workers need adequate training and support to deal with sensitive issues like child abuse. Aboriginal workers providing support services in their local communities need training, adequate supervision, support and mentoring support to be able to deal with the work and not get 'burnt out' by it. Workers may also need training in working with children and in working with children with cognitive disabilities.
Given that having an Aboriginal worker as part of the team is regarded as an effective way to encourage local community participation in programs, providing employment conditions which help retain Aboriginal workers is important. Flaxman et al (2009) notes that offering flexible employment conditions and a range of roles under different conditions (for example employing a number of people part time rather than full time), seconding Aboriginal workers from other sectors, training Aboriginal people to increase their capacity as mentors in the community, creating Aboriginal support roles to work with employees with professional qualifications and offering traineeships helped increase the recruitment and retention of Aboriginal support workers.
Research literature notes that effective programs need to build the capacity of local communities in order to become sustainable. For a program to become sustainable there needs to be capacity building at the individual, organisation and community level (Carson, et al, 2007). Santhanam (2005) observed that after four years the remote area child and youth mental health program had built most capacity within the service context through workforce development and improving support structures. This meant that it had increased its capacity to deliver services and was more able to engage the community, but had not made a measurable impact on community outcomes at that stage. Flaxman et al (2009) noted that mentoring local Aboriginal support workers was used in the Communities for Children program as a way of helping local people build skills and confidence to manage the service themselves.
Some literature also noted that the effectiveness of services would be assisted by a greater level of administrative support. Many remote service providers find the government accountability requirements onerous, particularly when they are operating on limited resources and are either understaffed or have inexperienced and unqualified staff. Where workers are in small teams or lone workers administrative tasks were particularly difficult to balance with existing workloads.
Ongoing monitoring and evaluation
The NT Board of Inquiry reported that programs Aboriginal people found successful were often discontinued without an evaluation involving their input. As part of the ongoing and effective dialogue process between government and non-government service providers and Aboriginal communities, evaluations of services needs to include Aboriginal views.Literature notes that initiatives which are regarded as successful or worthwhile by Aboriginal communities may not appear in the research literature, and that ongoing monitoring and evaluation is necessary to build a body of research which will allow good practice approaches to be developed and implemented.
Research literature says that evaluation needs to be part of the program planning from the outset and that it needs to be realistic about what can be achieved at the local level in the time frame. It must include Aboriginal involvement in the assessment of the program and in the program's intended outcome.
Carson et al, 2007 (p 287) suggests that the elements of a succcessful program are:
- Staff support (free workplace training)
- Good governance –open and honest dialogue between staff, management and councils
- Communication and shared information
- Reinforcing cultural protocols and awareness
- Leading to promotion of self esteem and a sense of identity
- Strong networking links with other agencies
Flaxman et al (2009) notes that measuring outcomes is difficult in remote locations due to lack of staff on the ground. When workers are collecting data they are not delivering services. Data collection can also be affected by the low literacy and numeracy levels in the communities. Santhanam (2005) also found that services need administrative support to assist with data base entries and outcome statistics.
In terms of evaluations of early counselling and support strategies for Aboriginal children and young people who have been abused, research literature finds that there been limited study in this area and more needs to be done.
In talking about therapy for inappropriate sexual behaviour, O'Brien (2010) states that children need weekly sessions for at least one year, with ongoing support over a longer term. This is problematic for most Aboriginal children and families in remote settings where access to services is limited. As noted previously, O'Brien (2010) and Purdie, et al (2010) also find that most clinicians working with children believe that therapeutic counselling needs to be ecologically based (ie in the local context) and involve family or carers where possible. They also suggest that children and young people can be traumatised if support services are withdrawn suddenly.
Santhaman (2005) found that communities value the regularity of support when it increased from visits once every 12 weeks to once every 8 weeks, but also noted that although community participation had increased, there had been insufficient time to observe any measurable effect on the community.
Some research literature suggests narrative therapy for Aboriginal children and young people with mental health issues, although notes that this needs more evaluation. Stanley et al (2003) state that Aboriginal communities have the notion of 'healing' which describes a dynamic and unfolding process of individual and collective problem solving. Again, there is limited evidence about this and further evaluation is necessary. Other literature notes ‚wellness. approaches and positive psychology approaches which build self esteem may be suitable for support interventions for Aboriginal children with mental health issues.
"Prevention is better than cure" - community education
Another key theme of the NT Board of Inquiry report is the need to balance resources between crisis intervention and taking preventative measures.Research literature specifically addressing the issue of child abuse in Aboriginal communities makes the link between unresolved childhood trauma and violence and the resulting impacts upon these children and their communities, such as increased risk factors for children and offending behaviour and patterns of intergenerational violence, sexually inappropriate behaviour and other ongoing detrimental impacts on health and wellbeing. (BIPACSA, 2007; Purdie,et al 2010; O'Brien, 2010). O'Brien also notes the dilemma for service providers with dual waiting lists for children who have been the victims of sexual assault and children or young people exhibiting sexually inappropriate behaviour which is indicative of past trauma and the potential to inflict trauma.
A key recurring theme in the literature reviewed is the importance of early intervention with "at risk" children and young people, and on preventative measures, such as education and whole of community approaches consistent with the public health model.
...preventing this therapeutic need in subsequent generations is not something that can be left to specialised counsellors. A whole of community approach is required, so that parents, teachers, law enforcement officers, health professionals, child protection workers and children themselves all understand the importance of respectful relationships. ... Strategies to educate children and young people about the moral and ethical responsibilities of relationships would be likely to effect a reduction in the number of juveniles detained on charges of sexual assault. Any reduction in the estimated 40-90 per cent of sexual offences perpetrated by adolescents would make a significant impact on the intergenerational cycle of victimisation and abuse. This ... highlights the need for integrated and holistic care for all Australian children who have experienced harm or adverse circumstances of any kind.
(O'Brien, 2010, p.101)
Research literature sees community education as a key early intervention on reducing the risk of child abuse. Effective early intervention and prevention programs should also be building local capacity, to ensure that interventions are sustainable.
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References
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