Better health and ageing for all Australians

Ways forward: national Aboriginal and Torres Strait Islander mental health policy

4. Trauma and grief: healing and reconciliation

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One of the most significant and frequent problems identified by Aboriginal people was “trauma and grief”. The impact on their health and mental health and well-being was seen to be extensive. The impact of trauma and grief relates to the history of invasion, the ongoing impact of colonisation, loss of land and culture, high rates of premature mortality, high levels of incarceration, high levels of family separations, particularly those consequent upon the forced separation of children and parents, and also Aboriginal Deaths in Custody. Domestic violence, sexual and physical abuse, and a whole range of other traumas also contribute. Sexual assault is considered to be very frequent and traumatic. These matters are discussed in depth below and in the analysis of needs.

Aims

To provide specific mental health services to deal with the particular and extensive effects of trauma and grief on Aboriginal people, including preventive and health promoting approaches, education, assessment, counselling, healing programs and community interventions, so as to diminish the adverse outcomes associated with such trauma and grief for Aboriginal people.

Policy initiative

The policy components proposed below aim to provide a comprehensive and interlocking set of mental health services to deal with this identified priority need, while linking to other policy areas as relevant.

Education about trauma and grief

There is a need to educate the general Australian community about the experiences of trauma and grief, their extent and effect on Aboriginal people. This education should be linked to processes of reconciliation and acknowledged by the wider community, as a stage in a public commitment to a healing process. Specific ceremonies, memorials or other ritual occasions may contribute to this acknowledgement and set a general ethos of healing. It has also been suggested (Hayden, 1993) that Aboriginal people may not themselves at times recognise that they are a "traumatised people" and that this contributes to their ill-health, for instance with substance abuse. Recognising trauma and grief, and education in ways of healing these, may have important public health outcomes for Aboriginal people.

Assessment of trauma and grief

The centrality of the experiences of trauma and grief for Aboriginal people mean that these aspects should be included in all assessments of distress and disorder amongst Aboriginal people. Furthermore it has been shown in other settings that bereavement may impact negatively on immune function (Bartrop et al, 1977) so that assessment and management of grief may also be relevant to physical health and well-being, in the holistic sense, synchronous with Aboriginal view of health. Family separation history and loss also contribute to mental disorders (e.g. McKendrick, 1993) so that it is appropriate that assessment address these possibilities. Counselling to deal with trauma and grief may be an essential part of management for many if not most Aboriginal people with mental health problems and mental disorders. It must also be further emphasised that the impact on physical health must also be considered.

Aboriginal cultural practices and death

There is a need for acknowledgement, recognition and practice which enables Aboriginal peoples to fulfil their particular cultural requirements about death and dying. These should include provision for healing with Aboriginal ceremonies and burials where these are wished for. This may include the deaths of babies, elders, and those who die prematurely. Hospitals and health care systems should be Culturally Informed, particularly those serving large populations of Aboriginal people, and should have policies and protocols to ensure Aboriginal ways of dealing with death and dying are provided for. There should also be full recognition of the importance of funerals for Aboriginal people and the greater likelihood of their wishing to attend because of extensive family/kinship ties, and high rates of premature mortality. Special requirements about not mentioning the name of the deceased and other cultural matters should be taken into account where these are required for the particular community. Special burial places are also helpful.

Prevention approaches

Clearly there needs to be specific policies to prevent undue trauma and loss for Aboriginal people and special sensitivity to the high background level of trauma and loss that are part of their experience. Thus there is a need for intersectoral and health care system interventions to prevent family separations which continue (for instance children into care, juvenile incarceration, separation with institutionalisation). It is also critical that health policies operate to reduce premature mortality, and where it occurs, deal with it in the most sensitive way, to thus facilitate grieving and resolution rather than additional trauma. The suggestions of explanations about premature mortality and its causes described by Rosas and Weeramanthri (1993) are likely to be helpful in this regard. Appropriate cultural practices are likely to be helpful in this regard, as is counselling aimed to prevent as far as possible pathological consequences of grief and trauma when these have happened.

Counselling for trauma and grief

There needs to be general availability of counselling services to help Aboriginal people deal with their experiences of trauma and grief as well as specific counselling to do with particular situations e.g. those that are consequent upon the forced separation of children from parents with transgenerational effects; those related to Aboriginal deaths in custody. Counselling formats need to be specifically developed in culturally appropriate ways to meet Aboriginal peoples’ needs in this area. Models such as those of Collard and Garvey (1994) provide this in a holistic framework. Other useful initiatives are Narrative Therapy (Howson et al, 1994) and Family Therapy. It is likely that such therapy formulations may provide framework of particular value also, because of the special expressiveness of Aboriginal people in this form i.e. story and narrative (e.g. Stone and Swan, 1994). There is likely to be a specific need to address these issues with children, particularly children in care. (see Section 6)

Counselling, in particular short term, has been identified as a very high priority for Aboriginal people particularly with respect to trauma and grief.

Counselling to deal with particular traumatic experiences is also needed. While there may be acute situations where models such as debriefing may be helpful, there is also the need for specialised counselling to deal with longstanding, past or profound, continuous and multiple traumatic experiences. For instance traumas of separation were often followed by adverse experiences of beating and threat for many Aboriginal children. It is also clear that many, boys and girls, were abused sexually. And many young women taken into domestic service were abused and raped by their masters. Aboriginal people experience not only trauma but profound shame. Recent increase in awareness of child sexual abuse has led to many of those who experienced this trauma when younger, being able to come forward and seek counselling and therapy.

Sexual assault is also, sadly, a frequent and traumatic experience for many Aboriginal people and may be associated with great trauma and shame. Counselling may be helpful in dealing with these issues and preventing further adverse impact on mental health.

It should be noted that special programs may also need to be directed towards children, young people and families.

Counselling issues as a general consideration for Aboriginal Mental Health care is addressed in detail in the Attachment to this Section.

Debriefing for stress, crises and critical incidents

Many violent, critical, and at times catastrophic events affect Aboriginal communities, in addition to the high levels of trauma and grief noted above. It has been found useful to provide a form of critical incident stress debriefing to communities at such times (Norris, 1993) with the aim of lessening the likelihood of ongoing community disruption and other negative consequences (e.g. payback, further violence). This form of debriefing may involve supporting community elders, and providing support, as well as focusing on the incident and helpful resolution of the problem (Norris, 1993). Its techniques are likely to be helpful in many such incidents in remote and rural and potentially also in urban communities.

Special healing programs and places

It has been suggested that there would be value in the development of special Aboriginal places of Healing, for instance in National Parks etc. and other relevant places of the land. It is proposed that Aboriginal people could visit and stay at such places and that this would promote healing. These places of healing should be developed with supportive programs with appropriate centres in each state.

Community interventions

While the above generally outlines ways of dealing with trauma and grief, these initiatives should be developed and determined at local levels in ways most appropriate for that community and its beliefs, by Aboriginal people. Special community programs, or guided interventions at a time of new major loss may be helpful in this regard.

Reunion and supportive organisations

The special contributions of organisations such as "Link Up" should be acknowledged and supported. Such groups facilitate reunion, shared grieving and often help to re-establish Aboriginal identity and kinship. They may provide counselling and education and have a special role in this aspect of the reconciliation and healing process. Their programs should receive special support and extension.

Rationale

The centrality of trauma and grief were repeatedly identified by Aboriginal people as one of the most critical issues affecting them. All groups reporting to the consultancy, both in face to face meetings, in individual reporting, as well as in the reports of medical and health services saw this as both a primary cause and a major area of problem and need.

A number of studies have identified the importance of childhood and later separations and losses as well as trauma as risk factors for psychiatric morbidity. These have been identified as relevant risk factors in the non-Aboriginal community (e.g. Raphael NH&MRC, 1992; Mrazek and Haggerty, 1994). Studies of Aboriginal people, as identified in the Literature Review have also demonstrated not only the high prevalence of such traumatic experiences, but also the adverse effects on Aboriginal Mental Health.

The Royal Commission into Aboriginal Deaths in Custody highlighted the vulnerability of those with a history of childhood separations in terms of high prevalence of such separations amongst Aboriginal people in such instances as a potential contribution to the suicidal behaviour. (RCIADIC 1991)

Radford et al (1991) in a sample of urban Aboriginal people found high levels of suicidal ideation and behaviours and that many had been separated from families and brought up in institutions. Similarly Clayer and Divakaran-Brown (1991) found risk of disorder correlated with separation and trauma, as well as possibly cultural loss.

Hunter (1993) examined suicide, alcohol problems and incarceration in the Kimberley. He examined respondents in the lock-up (usually for alcohol related problems), and concluded that a high proportion of these young men who were interviewed, especially those drinking heavily and with recent loss and disruption were at increased risk of suicide.

McKendrick and Thorpe (1994) describe the high levels of loss faced by Aboriginal people, and found in their studies that 63% of those presenting to Aboriginal health services had significant psychological distress (usually depression). One third had been brought up separated from families and communities, and such separations from their Aboriginal families correlated with prolonged distress.

The survey conducted by the Aboriginal Medical Service, Redfern, of Aboriginal Communities in New South Wales found substance use problems, stress problems, distress and anxiety were common. Childhood neglect, separation from parents and institutionalisation were the best predictors of mental disorders (Swan and Fagan, AMS Redfern, 1991, N.S.W. Mental Health Report).

Recent reviews have addressed Aboriginal people’s needs in this area - for instance, Hunter (1993b) and Marcia Langton on the issue of "too much sorry business".

A number of sensitive accounts have highlighted the impact of removal of Aboriginal children –for instance, "The Stolen Generation" by Peter Read and "Take This child" by Barbara Cummings. It has been estimated in one survey that 65% of Aboriginal respondents had been separated from one parent in childhood, compared to 29% for non-Aboriginal people; and 47% of Aboriginal respondents had been separated from both parents compared to 7% of non-Aboriginals (NAHS, p175). As noted in the Literature Review, death rates are double at all ages and up to five times that of non Aboriginal adults in some age groups (25-44). Maternal and perinatal and infant mortality are all substantially higher for Aboriginal people than non-Aboriginal people. Experience of violence, injury, accident, trauma are all more frequent for Aboriginal people, at least in some groups according to health care utilisation data, crime and other statistics. Past history brings childhood and transgenerational trauma and loss. There is an enormous "load" of trauma and grief borne by Aboriginal people and likely to contribute significantly to mental ill health for them. Research in non-Aboriginal communities has highlighted the vulnerability associated with such death and trauma "overload" (Wilson and Raphael, 1993).

There are no adequate studies of the nature of grief in Aboriginal communities except the work of Reid (1979) describing bereavement and grief in the Yolngu in Australia. Selby (1994) in a general survey of attitudes to death, dying and bereavement in different cultural groups, and noted a wide range of beliefs and practices.

There has been no attempt to assess or investigate the consequences of trauma in terms of post trauma morbidity such as Post Traumatic Stress Disorder or Complex PTSD (Herman, 1992) and vulnerabilities such as borderline personality traits/disorder, substance abuse, and self harm. Post trauma morbidity could explain many of the patterns of problems experienced by Aboriginal people and warrants further exploration and research.

Of particular significance is the possible impact of trauma, separation, loss and grief on physical health. As noted above, there is demonstrated impact on immune functioning (Bartrop et al, 1977). Sibthorpe (1988) has postulated impacts on physical health status, as have recent reviews. These aspects must be factored into considerations of the ongoing adverse physical health outcomes for Aboriginal people.

Reports and recommendations

Presentations at the National Aboriginal Mental Health Conference (November, 1993) indicated that Trauma and Grief were of critical concern, and repeated papers drew attention to these issues. A video of these presentations highlights the ubiquity and importance of trauma and grief and the need for counselling for these. Submissions explained the need for services to deal with grief and loss (p3 1), the need for Aboriginal cultural practices in relation to death (p29).

Specifically it was recommended by this conference:

"That the Federal and State Governments acknowledge the trauma and grief that has been caused to Aboriginal people and provide resources to Aboriginal people to develop healing and counselling for the trauma and grief, and policies to prevent further trauma and grief"
(Report on National Aboriginal Mental Health Conference 1993, p33).

"That Aboriginal health services develop mental health programs to address
  • Sexual assault
  • Grief and Loss"
"That Link-Up be resourced to provide treatment and healing to their client groups."

"That there should be an extension of funding and support of programs such as LINK UP and ANOPS which examine and 'treat' the efects of separation from families (i.e. community driven support services).

“That the money promised by the Commonwealth Government and ATSIC to the families of Aboriginal people who have died in custody for grief counselling be released immediately."

"That the Federal and State Governments and all other relevant organisations recognise the severe and adverse efects of the dislocation of Aboriginal people from their lands and disruption of their families and take all possible measures to prevent further dislocation and disruption because of the very adverse efects on mental and physical health and well-being ".


"Aboriginal families"

"That family links be encouraged especially with the extended family by:
  • breaking the cycles of kids being placed in care from mothers who were in homes.
  • talking out and resolving family problems after separation ".
"That putting people back in touch with their families is a priority in achieving Aboriginal well-being and mental health."

"That the importance of grieving the loss of family caused by forced removal of children be acknowledged."


Aboriginal cultural practices and death

  • "That the use of ceremonies for dealing with death be promoted by:
  • healing through Aboriginal customs and burials.
  • being assertive with funeral directors to get what you want and in control.
  • need to ask for what you want e.g. getting a tombstone, Aboriginal people reclaiming their practices as therapeutic.
  • need to look not only at individual grief but also family and community grief.
  • workplaces to recognise need for Aborigines to attend funerals and to leave work swiftly.
  • need to educate Aboriginal workers to do grief and loss work.
  • use non-A boriginal professionals as resource people.
  • need to educate doctors especially when delivering babies to be koori sensitive especially if baby dies.
  • Aboriginal cultural awareness needed in all hospitals.
  • stop sterilisation of Aboriginal women, take control.
  • Non-Aboriginal people to learn about Aboriginal culture ".
The families request that services be made available immediately to help address the suffering and grief and provide opportunities for healing. The services need to be planned by the families to meet their individual needs.

National Goals and Targets for Mental Health (1994) have also identified trauma and grief as major areas to be addressed with specific counselling and prevention programs. In terms of equity it is thus also essential that such approaches are provided for Aboriginal people.

Submissions to the Consultancy

Trauma and grief, the removal of children, and separations were one of the most frequently identified causes of mental health problems from all sources: Aboriginal Medical Services, individual presentations. This matter was repeatedly discussed at all meetings, was frequent, and central and identified as an urgent priority and major need. It was seen as central to all mental health issues by Aboriginal people (See Consultancy Report).

Strategies

Under the auspices of the National Aboriginal Mental Health Advisory Committee, and monitored by this group.
  1. The National Aboriginal Mental Health Advisory Committee will liaise with the National Council for Aboriginal Reconciliation to develop a National Program for Healing, Trauma and Grief, including a series of working papers and educational programs for education of the broader community and Aboriginal Communities on the trauma and grief experienced by Aboriginal people, the importance of supportive and healing approaches to deal with these, as well as the critical importance of preventing further separation, loss and trauma. This National Program should be able to be adapted at regional levels and linked to appropriate local programs and responses. The National Programs of Healing, Trauma and Grief should include factual information on historical factors such as forced removal of children, but also current high levels of premature mortality, and preventable separations of children and families, and support for the development of rituals, ceremonies and memorial processes to facilitate resolution, taking account of what is known of the beneficial effects of recognition, acknowledgement and testimony. Use of videos on Trauma and Grief plus presentations from the National Mental Health Conference would be valuable in this matter.

    This National Program for Healing, Trauma and Grief should also incorporate recognition of art, dance, writing, theatre and other creative endeavours to facilitate the working through of these experiences and to provide positive support for prevention. The National Program for Healing, Trauma and Grief should also provide an intersectoral environment for the examination of present day policies to assess these to ensure their modification to minimise further separation and trauma (for instance of children and families) and promote recovery.

    Within such policy review and this overall program, it is vital that appropriate recognition is also given to Aboriginal cultural practices, including opportunities for family reunion, attendance at funerals, and rites required in different communities to do with death, dying and bereavement. This National Approach also needs to ensure positive and empowering aspects of dealing with trauma and grief so as not to create a "victim" culture in this context, but rather link to the Positive Survival themes that have been successfully used by Aboriginal people. It is also important that there is recognition of the transgenerational transmission of the impact of trauma, and loss (e.g. Danieli, 1993; Oliver, 1993) and that opportunities are taken to prevent further consequences in the future.
  2. Clinical policies, protocols and programs should be developed building on successful programs and oriented to identified needs. In this context it is necessary that policies and regional programs for mental health include recognition of the contribution of trauma and loss and provide
    1. Therapeutic assessments of the aspects modified to formats appropriate for Aboriginal people (Raphael, 1983).
    2. Counselling programs and other interventions to deal with the distress associated with trauma and grief and the psychosocial morbidity that correlates with this.
    3. Healing places or programs identified as important by the community in terms of particular aspects of trauma and grief.
    4. Special bereavement programs for deaths by suicide and for families and all those affected.
    5. Special counselling programs for those who have recently or in the past suffered sexual assault; sexual abuse; other traumas.
    The presence of such programs and the use of traditional mourning, recovery or healing as well as professional counselling, should come under the brief of the Regional Mental Health Forum, and should be provided through Aboriginal Community Controlled Health Services through Mental Health teams as appropriate. The links to general health are also critical and counselling may need to be specifically provided in terms of
    • communicating appropriately about the death (see above)
    • high levels of maternal and infant mortality and in association with the women’s business of health in these contexts.
    • premature deaths of adults, especially deaths from external causes such as violence, road deaths, suicide, homicide.
    • deaths of community leaders.
    • deaths in custody.
  1. Stress debriefing. Each region of Community should have at least one and preferably two persons identified and trained in stress debriefing. This model should be one such as that of Norris (1993) which is appropriate to a range of Aboriginal community settings. Ideally these programs should be carried out in collaboration with community leaders or elders, in the model of their special support (compare peer support programs in current C.I.S.D. programs). It is critical that people realise such programs should not stand alone, but be part of a safety net of mental health support and counselling follow-up after major incidents.
  2. Education about trauma and grief. The Education and Personnel Development Working Party needs to ensure courses for education and training in counselling and community interventions so as to deal with trauma, and grief. These should be developed in culturally appropriate formats. This strategy should include ensuring adequate and specific coverage of these aspects within courses for Aboriginal Health and Mental Health Workers, and coverage by Mental Health Professional Curricula. These courses should cover both content and skills. They should also cover special aspects of counselling such as that for grief, for sexual assault, for long term effects of abuse, for past separations and losses, and for all those forms of trauma and grief experienced by Aboriginal people.
  3. Healing Places or Centres to facilitate understanding, prevention and healing should be established. These should be responsive to local need and be used for the development of preventive approaches, healing, reconciliation and memory, as well as symbolising Aboriginal strengths and Survival. Elders could facilitate this process of continuity, growth and cultural development.
  4. Research and Understanding should be promoted to further understand the particular issues of trauma and grief for Aboriginal people, strategies to deal with them, counselling modes and the impact on physical and mental health of individuals and community well-being. There is a need for specific research into PTSD and how it affects Aboriginal people and its links to other disorders/problems particularly Substance Abuse and physical health problems. A national network of Aboriginal people could address these issues, and develop a resource of knowledge in this sphere, as well as factors facilitating resolution.

Targets

  1. The National Aboriginal Mental Health Advisory Committee should review current understandings, liaise with the Council for Aboriginal Reconciliation, develop a specific set of goals for the proposed National Program for Healing, Trauma and Grief and produce at least one Educational program, evaluate it and disseminate it nationally by end 1996. Further programs relevant to Education, Community Consultation, Healing and reconciliation with respect to Trauma and loss as part of the National Healing Program should be implemented by end 1997, with a complete program by end 1999.
  2. Clinical policies and protocols should be established by end 1996 with programs of personnel education in trauma and grief by end 1996 and counselling programs in all larger communities (> 3000) by end 1997.
  3. Stress Debriefing Courses should be provided for mental health workers by end 1995 and stress debriefing coordinators or debriefers established in larger communities by end 1996.
  4. A review of Trauma and Grief Education Programs and specific courses and course or curriculum accreditation should be carried out by the Education and Personnel Development Working Party by end 1995 with courses in place by end 1996. Short courses for workers in place, including video, distance education and local seminars should be developed by end 1995 to facilitate work in this sphere.
  5. Healing Places or Centres should be established in each State in areas or regions or significant sites developed by Aboriginal people. There should be at least 3 such places established by end 1996 and relevant prevention and networking by end 1997.
  6. Research programs should be developed and special initiatives should be provided to fund Mental Health research by Aboriginal people to explore the impact of trauma and grief on mental health and patterns of survival and pathology that may result. There should be supported funding for this aspect, through NH&MRC special initiatives, RADGAC, or other relevant agencies.

Attachment - Counselling

Counselling has been repeatedly named as a greatly needed intervention for Aboriginal mental health, and an essential part of service provision. It is also considered essential that counselling be developed and provided in culturally appropriate ways.

Nevertheless there are few defined models of counselling for Indigenous people; or models that have involved “talking treatments” that have been shown to be effective for Aboriginal clients.

There is also an identified need for educational programs, both brief and more intensive, to give people the necessary skills to carry out this work.

Counselling is seen as needed to deal with a wide range of problem areas, so that both generic and specific expertise is required. Areas of need that are seen to be of particular priority are those to do with
  • Trauma, loss and grief including the effects of separation, deaths in custody and effects
    through the generations of removal, loss of land
  • Violence and Assault
  • Sexual Assault
  • Relationship, and family including breakup of relationships
  • Children’s and young people’s problems and disturbed behaviour
  • Alcohol and drug problems
  • Depression
  • Child Abuse, especially childhood sexual abuse and its adult consequences
  • In preference to treatment with medication
  • A range of other areas
Counselling, in terms of talking therapy and mutual support, may be of such value that it should be understood, and its elements be able to be utilised widely by all members of the community (Rathman, 1995) to support and help one another.

Particular emphasis is repeatedly placed on the importance of counselling being in forms appropriate for Aboriginal people’s culture and understanding.

Particular organisations have been identified as providing counselling – e.g. Link-Up (New South Wales). This organisation provides counselling to families and individuals who have experienced removal and separation, to address grief and loss, to facilitate healing and recovery. "Mental healing and social acceptance", with pride in Aboriginality, is a focus for this work, with a positive emphasis on the future. There is a need for "better health services in areas of counselling, and mental health". (Kendall 1994, p19)

In a series aimed at increasing awareness of Aboriginal Mental Health issues in the Aboriginal Health Worker Journal, Hunter 1993(c), deals with the question "just talking – or communicating". This useful paper clarifies a number of key requirements for effective communication: attitude, including acceptance, interest, concern, flexibility: competence; behaviour including distance, engagement, attention, encouragement; communicating verbally including clarity, delivery and direction, silence, assistance; delivering information including simplicity, accuracy, relevance, emphasis, repetition, ending, including summary; questions, expectations, availability. Clearly this presentation forms the basis for elements of extending into counselling and contributes in terms of basic skills.

Particular initiatives for counselling have been developed. One of these is "Narrative Therapy", described by Howson (1994) and taught in a course through the Aboriginal Community Recreation and Health Services Centre of South Australia Inc. This type of counselling derives from the model of Narrative Psychotherapy described in mainstream psychiatric literature and has evolved with this group through a consultative process with Michael White, Family Therapist. It is seen as a model of particular value to Aboriginal people in that it builds on the story telling and talking modes that are a central part of people’s culture. The leaders of this course see it as providing "advanced counselling skills applicable across many problem areas".

A specific course to teach counselling for mental health has been developed at the Curtin University Western Australia, Centre for Aboriginal Studies. Collard and Garvey (1994) describe the program in some detail and the ways it talks about "mental health". These workers also identify the need for "practical and experimental training formats, culturally appropriate ways of counselling Aboriginal people, for Aboriginal people" (p17). They go on to state that counselling needs to be at community, family and individual levels. This course builds on the holistic model of mental health, mental health and well-being, coping difficulties, and problems. The course has a positive orientation, takes into account emotional, physical and spiritual well-being, the physical environment and its impact, the past and the present. The person’s future goals and dreams are examined. Counsellors are encouraged in problem solving and goal setting skills, so as to assist others in these areas. This approach suggests a range of intervention options and that people can call on a range of resources to deal with their mental health problems, including psychiatrists. The diversity of treatment options, it is felt, should reflect the diversity of Aboriginal and Torres Strait Islander peoples.

Pat Dudgeon and Sandra Collard (1993) speaking at the National Aboriginal Mental Health Conference, described the necessity for such a Counselling course. (National Aboriginal Health Strategy, the Burdekin Enquiry and the Western Australia Health Needs Survey all strongly indicated these needs.) The Curtin Aboriginal Counselling Training and Development Program evolved in response to these. It provides educational programs for Aboriginal people in their workplaces, and linked to their real experiences and needs, examining both concerns and strengths of individuals and communities. It also operates not only to deal with symptoms and their management, but the options for individual and collective action to deal with causes. Hence it has a community development context, and this provides the opportunity to deal with the causes of mental distress affecting Aboriginal people at all levels. This program clearly offers options for preventive as well as therapeutic interventions.

The approach described sees holistic mental health care as contributing to prevention as well as treatment. The individual is viewed in his or her context as a whole person "Within a broader network of people, places and organisations" (p20). Interventions may be primary, secondary or tertiary to prevent mental ill health. The course is said to be based on principles of empowerment. This includes a "shared learning processes", building on skills Aboriginal people already have in dealing with mental health issues: these skills and strengths are acknowledged and affirmed.

Most of the educational programs identified in recommendations indicate that counselling is an important intervention for Aboriginal people’s mental health needs and the need for this to be culturally appropriate. It is identified as a general need for Aboriginal health workers and specifically for programs to educate Aboriginal Mental Health Workers. However specific details of such counselling education programs are not available.

Recommendations from the Royal Commission into Aboriginal Deaths in Custody identified the need for family counselling, particularly family counselling services for grieving families and some initiatives have been put in place to address this, for instance in New South Wales, a Family Counselling Meeting was set up to ensure the development of necessary programs. It was considered that such family counselling needed to be made as broad as possible, taking into account extended family, cell-mates and friends. It was considered that there was a need to establish definitions of counselling, and who should deliver it and where, as well as to whom it should be provided. There should also be an intervention program put in place to prevent deaths in custody. It was suggested that there was a need for mainstream counselling services, particularly as young people were reluctant to use juvenile justice services. There was seen to be a need for a data base on counselling services. In particular there was seen to be a need for an identified Aboriginal Health Worker in each area with counselling and Aboriginal cultural experience, who could help access appropriate counsellors and respond to develop programs relevant to past or continuing need. Initiatives in other States are also attempting to address the needs for counselling, but many approaches were seen to be fragmented, many families had not received counselling, nor were there programs for the ongoing bereavements that were occurring. The Recommendations of the National Mental Health Conference and reports from those attending also indicated the high levels of distress and the enormous unmet need.

Theoretical bases for counselling for Aboriginal people

Recent theorising and initiatives from Australian psychologists (e.g. Reser, 1994) discuss the need (or otherwise) for an "Aboriginal psychology". Reser suggests that, for instance, when considering the question of alcohol related violence, differing viewpoints for interpretation of a wide range of possible contributing factors, could "carry very different intervention and prevention implications in terms of assessment, risk identification, counselling, clinical intervention" (p6) and actual understanding. He goes on to suggest that it would ultimately be more helpful to develop a "global perspective", which would challenge western psychology, could allow expression of "the diversity of voices to represent the human experience: This would require a "new understanding of personhood and involvement and concern with third and fourth world issues and collective experiences" (p9). Bolton (1994) in the same volume emphasises that Aboriginal people may need not only "culturally appropriate counselling" which empowers spiritual as well as other issues, but also traditional healing practices. This is similar to the call from Garvey (1993) at the National Aboriginal Mental Health Conference for a "new language for mental health based on a synthesis of indigenous and imported philosophies".

Miller (1994) examines the constitution of Aboriginal mental health and makes a case for an indigenous psychology to deal with "academic colonisation" that has occurred from western models. She believes psychology should be harnessed to "empower Aboriginal people and communities" that this should occur through community education, positive small group interaction, and altering power structures. She also significantly suggests the need for "decolonisation therapy" for Aboriginal people who have been adversely affected by colonisation. Aboriginal psychologists need to be trained and courses (such as the community psychology course at James Cook University and others around the country), need to develop programs to educate Aboriginal people in "culturally appropriate" counselling - "decolonisation therapy" so that Aboriginal people are “enabled and empowered to overcome feelings of grief, powerlessness, alienation and depression at loss of land and culture and loss of family members due to violence and suicide (p26). The approach also incorporates a different power structure of therapy which is seen as more equal than traditional therapies.

A number of publications have attempted to consider the issues of transcultural counselling and a bibliography of some of these has been drawn up (Alladin, 1993). A number of these may be relevant but none specifically address the issues of Indigenous populations such as the Australian Aboriginal people.

Cawte (1986) has written on Aboriginal healing from the point of view of "Psychotherapy". He discusses his contact with a number of Aboriginal people in talking therapies over the years, and sees it as helpful.

Other workers also address needs for counselling - for instance in Alcohol and substance abuse programs. Hunter (1993 a) describes the contribution of health workers working with bereaved people in providing care and support. However he goes on to suggest further aspects, such as exploring family support, being able to listen to the grieving person and allow their tears. There may be a need to help them express ambivalent feelings about the person who has died, or anger. It may also involve being there for the person when they need to talk and helping them to "let go". He also describes the work of a mabarn man in the Kimberley, a talking and touching treatment for a grieving woman. These approaches clearly contribute forms of bereavement counselling.

Presentations to the National Aboriginal Mental Health Conference frequently addressed the needs for counselling, and models that had developed. Rosemary Wanganeen in her presentation (published in Aboriginal Health Workers Journal, March 1994) described a seven phase model of "self-healing" and spiritual reconnection, which suggested a basis for elements related to counselling processes. These phases were: Phase one – Aboriginal History, cultural and spiritual; Phase two – the Aftermath of the invasion; Phase three – Identifying past physical experiences and origins in childhood, adolescence, adult life; Phase four – Identifying emotional legacies and connecting them to past physical experiences (including earlier generations); Phase five – Working with and through phases 3 and 4, with grieving processes and forgiveness processes; Phase six – The journey to find the real you and your purpose in this lifetime. Phase six involves releasing "negative energy"; Phase seven – making your connection to your spirit and our spiritual ancestors (Wanganeen, 1994, p9–15). This presentation emphasises the importance of positive self healing and each person's responsibility for this. The model, the journey, and the personal ownership are the essence of many good counselling models. Pat Lowe, at the same meeting, talks of the common emotional needs of all peoples and that while there is a need for professional counsellors (Aboriginal) the natural abilities of some people should also be used for roles as lay counsellors.

This model was used in Broome to support Aboriginal people in custody. She emphasises too, the need for Aboriginal people to be involved in counselling, to preserve Aboriginal people's own cultural way.

Recommendations from the National Aboriginal Mental Health Conference (Report, Swan and Raphael, 1994) also addressed counselling needs (see Appendix A also).
  • "That the money promised by the Commonwealth Government and ATSIC to the families of
    Aboriginal people who have died in custody for grief counselling be released immediately."
  • "That Aboriginal Children's Services be resourced to provide culturally appropriate mental
    health and counselling services to their client group."
  • "That funds become available for existing Early Child Care Centres for:
  • counsellors for child/parent and staff needs"
  • "That Aboriginal ways of counselling, Aboriginal ways of healing be identified."
  • "That the Federal and State Governments acknowledge the trauma and grief that has been
    caused to Aboriginal people and provide resources to Aboriginal people to develop healing and
    counselling for the trauma and grief policies to prevent further trauma and grief."
  • "That Aboriginal mental health workers be educated to work with children and adults alongside existing services e.g. Aboriginal School Counsellors."
  • "That Aboriginal people working in the Aboriginal community and doing counselling as part of their duties (specified or unspecified) be entitled to attend counselling skills courses and receive any ongoing training they feel they need to perform their job adequately. LINK UP (NSW) be involved in educating Aboriginal and non-Aboriginal mental health workers (on effects of removal)."
  • "That there be an injection of funds into all levels of training/education in Aboriginal mental
    health, i.e. lay counsellors and Aboriginal health visitors, undergraduate health disciplines
    and graduate/post-graduate specialty education in Aboriginal mental health."
  • "That relevant State and Commonwealth funding authorities be informed about the urgent need
    to fund courses that enable Aboriginal people to gain qualifications in psychology that are
    approved by relevant State Registration Boards and the APS."
  • "That Aboriginal women's refuges be resourced to provide culturally appropriate counselling and mental health problems to their client group."

Aim

To develop, test and implement a range of effective counselling models and programs for Aboriginal people.

Policy initiatives

There is a need for Centres as above and other groups to be supported in their Educational Service and Research contribution to the development of Counselling for Aboriginal people.

Strategies and targets

  1. Support be provided for Counselling education programs as part of Aboriginal Health Worker Education. (see Section 15)
  2. Research to explore counselling models and their effectiveness be developed by and with Aboriginal people and appropriate researchers and be supported by special initiative funding through NH&MRC, RADGAC or other groups.
  3. A National Workshop to develop a resource on Aboriginal and Indigenous counselling and to explore its parameters be coordinated by end 1996.