Ways forward: national Aboriginal and Torres Strait Islander mental health policy
There has recently been increased recognition of the particular factors contributing to the mental ill-health of women, and the high rates of mental health problems experienced by them. There is a lack of systematic data for the general Australian population, and a proposed National Mental Health Survey should address this to some degree, providing gender biases do not diminish the full assessment of the spectrum of problems facing women and men. No National systematic data exists concerning Aboriginal women, but what data is available (e.g. McKendrick, 1993) supports the view that the problems they face are at least as prevalent as those of non Aboriginal women, and probably more so, because of their history of trauma and loss, the impact of colonisation and the disadvantage they continue to suffer.
Thus it is important that policy development, as for the non-Aboriginal community, specifically address Aboriginal women's mental health needs.
AimTo develop mental health responses of promotion, prevention and specific services to enhance Aboriginal women’s mental health and to improve upon factors that contribute to their mental ill-health; with special reference also to those disorders that are more prevalent in women or occur only in women.
Policy initiativesIn terms of Aboriginal views of the importance of considering families as an entity, or group with interpersonal connectedness, some issues of women's mental health can be dealt with optimally in conjunction with programs relevant for men, and cannot be considered totally separately. Thus policy initiatives should not be seen as negating those necessary for Aboriginal men, but as complementary. At the same time it is important that some matters linked to women's issues, such as mental health aspects of women’s sexual and reproductive health, should have specific and 'private' levels or initiatives.
Policy initiatives also, importantly, must link to social justice and equity considerations for women. Aboriginal women, as noted above, may have a different perception of the equity issue of relevance from those of the broader community as they have concerns that Aboriginal men may be also grossly disadvantaged in status, socio-economically, and so forth. Thus the wish to stop violence may not be seen as part of the wish to negate men, but is seen often as the result of the shared environment and experience of colonisation, dislocation, and continuing disadvantage. Aboriginal women present significant concern about the problems faced by Aboriginal people, Aboriginal men, and the need to address these problems through a holistic health care model.
Violence and its consequencesPrograms to deal with violence against women should be part of an integrated approach to prevention in this field, and involve men’s programs (see next section) as well as community wide initiatives. These matters will also be dealt with in the Policy Initiatives for Prevention (see Section 10). A number of community groups have already developed programs for Aboriginal women to help them to prevent and deal with violence and abuse. These are generally healing programs (e.g. Atkinson, 1994, We Al-Li).
Program elements include:
- Violence is unacceptable. Community programs need an active educational component that provides the message all aspects of violence are unacceptable, but that violence to women is especially unacceptable (as is violence to children). Sanctions reinforcing that such violence is shameful, encouraged by a decrease of community denial of the violence of Aboriginal men to Aboriginal women (and to a lesser degree vice versa) should be part of this program. It would be of particular importance for each relevant community to seek solutions and support a change in these community attitudes. As violence may be context and time specific - for instance related to drinking and pay or money phases of the week, or after funerals, special programs targeting these times and behaviour that follows them could be helpful.
- Women's groups. Groups of women provide relevant support, plus opportunities for specific education/counselling/social networks. These groups may be used to help women to develop ways to prevent violence in some instances, and to support one another to stand up against it in their communities. In such groups it may be possible to develop techniques that are non violent to help resist violence individually as well as generally for communities.
- Healing programs. Such programs can specifically address the issues of dealing with past trauma such as child abuse, as well as healing current effects of violence. One such model, the We Al-li program utilises the concept of a healing circle using Dadirri – an "inner depth listening and quiet still awareness"; workshops such as "lifting the blankets", and "recreating the circle" (Atkinson, 1994). Other healing models, for instance that of Rosemary Wanganeen's 7 phases of self-healing may also be appropriate. Communities should develop and use models seen as appropriate by Aboriginal women and the specific culture of their own communities.
- Sexual assault and abuse. There is a specific need to address sexual assault and its consequences for women, as this is frequent and traumatic and impacts on all aspects of women’s lives. Similarly Abuse, both past and present, should be provided for in a range of programs.
- Counselling. Specific counselling for those affected by violence needs to aim at mitigating the post traumatic morbidity, breaking the cycle of violence, and healing those traumatised by it. All this should be provided in culturally appropriate counselling frameworks, and by Aboriginal people who are skilled to respond to these needs.
Women's issues related to reproductive healthThere are a number of components that can contribute to enhancing Aboriginal Women's mental Health with respect to their sexual and reproductive health.
- Young Women's programs to enhance self-esteem, encourage self-worth and support to develop work and role expectancies that are rewarding, including those that may help delay early pregnancy. These programs include education, group support, cultural programs, Grandmother programs, schools programs.
- Psychosocial care for pregnancy, childbirth and post-natally. These elements should be provided through Aboriginal Health, Women's Health and Mental Health program levels and increased awareness of the special psychosocial issues for Aboriginal women, for both Aboriginal and non-Aboriginal care providers. Enhanced opportunities for involvement of Grandmothers and other women, and traditional birthing when this is preferred, should be encouraged.
- Support, education and parenting support (e.g. Aboriginal home visiting, linked to enhanced detection of child rearing problems, and problems such as post natal depression) This program should be part of that for children and young people above and include parenting support options, and also linked to the Aboriginal Community Mental Health Program.
- Counselling. Special "women's business" counselling provided for Aboriginal women, by appropriate women, should be available for both prevention and treatment of Aboriginal Women’s problems in this area.
Other aspects of women's mental healthProblems such as stress related to women's roles in the home, (e.g. lack of money, poor housing, managing large households); caring (for children, the ill, the handicapped, the mentally ill); cumulative stress of women's responsibilities e.g. the "stressed-out granny syndrome"; work stresses of multiple obligations, for instance for Aboriginal Health Care Workers; problems of single parenthood, for instance with young mothers, and the high levels of incarceration of Aboriginal men; past stresses and current effects of history, loss and separations; and many other factors may contribute to mental health problems for Aboriginal women. Most can be prevented or managed by three key program components
- Education about issues and coping
- Supportive networks and groups with other Aboriginal women and perhaps elders
- Counselling oriented to these issues and in culturally appropriate frameworks.
RationaleThe Literature Review identified the fact that mental health problems occur for Aboriginal women and on the limited information available, are at least as frequent, and perhaps more so, than those affecting non-Aboriginal women. Depression is prevalent, in the limited systematic data available, as indicated by McKendrick (1993) and McKendrick and Thorpe (1994) and correlates with experiences of separation and other factors. Radford et al (1990, 1991) report a very high prevalence of self-harming and suicidal thoughts and behaviours which correlated strongly with adverse environment and social factors, as well as early separation experiences. No specific studies appear to address women’s mental health issues further amongst Aboriginal women. The limited hospital separations data available, also supports the findings of depression, self harm and to a lesser degree but still frequent, anxiety conditions as significant mental health problems for Aboriginal women.
Some general features of Aboriginal women’s health are relevant to their mental health. They have higher fertility and birth rates, but higher infant mortality than the non-Aboriginal population. They have births at a younger age than non-Aboriginal women and there are more young mothers. While they have higher rates of unemployment than non-Aboriginal women, their rates of employment grew more than those for Aboriginal men. The life expectancy of an Aboriginal woman at birth is up to 20 years less than for non-Aboriginal women. More Aboriginal women live in multifamily households. One parent families usually headed by an Aboriginal woman comprise 27% of indigenous families, almost double that of the non-indigenous population.
A higher proportion of Aboriginal women than non-Aboriginal do not drink, but of those that drink a high proportion do so at hazardous levels.
Thirteen percent of Aboriginal babies are low birthweight, more than twice the rate for non-Aboriginal babies. This low birthweight may be associated with higher rates of still-birth and neonatal deaths. There is a much higher rate of foetal alcohol syndromes. The incidence of antenatal complications is higher and STD’s more frequent (de Costa et al, 1994). These low birthweight babies constitute an additional stress for the mother. Other differences, for instance in sex – specific mortality parallel the pattern seen in non-Aboriginal people. Post natal depression among Aboriginal women was reviewed by Anny Druett (1994) as part of a consultancy to the New South Wales Health Department. She reports that there is an abundance of anecdotal evidence to support the fact that it affects Aboriginal women, but no systematic data was found. The consultation process found that post natal depression had not been adequately recognised as an issue and that it was often difficult to tell others about depressed feelings, particularly male doctors, as it was considered to be women’s business. There was seen to be a need for increased community awareness, and information provided to Aboriginal Medical Services and Aboriginal Health Workers on this issue. It was also seen as difficult to diagnose the nature of distress and other issues that Aboriginal women might face (particularly with perinatal morbidity and so forth). It was seen as necessary to make post-natal depression known not only to childbearing women themselves, but also to grandmothers, aunts, and other community members, as well as women’s groups. There was a need for support systems and groups as well as education of Aboriginal midwives and others to deal with it, and the need for more female doctors. There was also seen to be a need to enhance current management practices by cultural awareness programs for those who cared for Aboriginal women through the childbirth period. It was also recommended that there should be special strategies and programs to deal with post natal depression affecting Aboriginal women, including groups and these should be developed by and with other Aboriginal women.
Clinical screening and all mothers being given time and opportunity to discuss their feelings about themselves after the birth of their babies, were seen as preferable to questionnaires such as the Edinburgh Postnatal Depression Scale. Critical to all these developments was the need for culturally sensitive and appropriate educational programs to enhance the detection and management of post natal depression among women in their own communities. This should apply to non-Aboriginal, as well as Aboriginal health workers, including especially midwives, and obstetricians.
Brady (1992) in considering the health of Aboriginal young people, has drawn particular attention to the issue of childbirth among adolescent girls and the social and cultural issues that surround these youthful childbearing experiences. These younger mothers are more often vulnerable to complications, single and sometimes unsupported. They are less likely to attend for adequate antenatal care and more likely to have problems. Their children may be given over to granny-care and the young women themselves may feel they have lost the gain and status that having a baby meant, and are burdened by the reality. Clearly there are profound psychosocial issues for mother and infant in this setting as well.
Other issues of Aboriginal women's health may also be relevant to their mental health, but data is at the present lacking, although a survey in Sydney (McIlwain et al) may provide much needed information, as may the proposed Longitudinal Women's Health Study.
Aboriginal women's experience of violence has been reviewed by Audrey Bolger 1991). She describes "fights" in traditional communities, the majority of which could be seen as taking place for traditional reasons (e.g. children, jealousy, swearing, ceremonial) but others related to Western influences such as money, alcohol.
However reports suggest that much of the increasing violence in communities is directed towards women. While data on prevalence are limited, she quotes a report by Pat O'Shane to the New South Wales Task Force on Domestic violence, who found, on her report, that it had affected nearly every household. Violence experienced by Aboriginal women ranges from child abuse, particularly sexual abuse, to bashing and domestic violence in the home, and to rape. Bolger also notes that while non-Aboriginal women experience domestic violence, there appear to be few Aboriginal women who have not experienced it. Aboriginal women may also be attacked by a wider group of relations, and are more likely to be attacked with a weapon. The perpetrators are usually Aboriginal, and the violence may result in death. Many women do not disclose, both because it has been accepted as part of their lives (until perhaps recently) and because they do not want their men to go to goal.
Domestic violence in an urban Aboriginal perspective has recently been reviewed by Muriel Lucashenko and Odette Best (1995). These writers suggest that Aboriginal people in urbanised Australian experience violence on a daily basis, which ranges from psychological hostility through to physical brutality. They go on to state that "for Aboriginal women and children this daily violence is not only public but also has a private, Black on - Black dimension" (p19). As these workers state, there is virtually no comprehensive research into levels of women bashing in urban Aboriginal communities, so evidence is either anecdotal or drawn from hospital statistics.
The report of the National Committee on Violence (1990) states that "the level of violence existing in some Aboriginal communities is of a scale that dwarfs that in any sector of white Australia". (p165)
Reports and other initiativesThe National Women's Health Policy identified a number of major areas to be addressed with women. These included women’s mental and emotional health; women’s reproductive health; women’s experience of violence and abuse; status of women issues; and other matters.
The NH&MRC Report, Women and Mental Health (1991) examined the extent of mental health problems of women and gender differences; mental health issues related to: reproductive biology; life cycle and development; including conflicts and stress in adolescent girls and ageing; women and violence; women, work and unemployment; women in a multicultural society; women in their social roles including women as carers; mental health care and health care for women.
The National Women's Health Policy identified Aboriginal women as a special needs group. The report Women and Mental Health, calls attention to the special needs of Aboriginal women (pages 42-43) and the importance of further research to assess their mental health problems and needs.
The National Aboriginal Health Strategy addresses Women’s Business, women's health issues (p179-191) from the point of view concentrating on maternal and child health services; sex education; women's business and mainstream services; family planning; infertility; culturally appropriate birthing centres; early first pregnancy; antenatal and postnatal care; cervical and breast cancer screening programs; health awareness education and promotion programs for women. Strategy areas relevant to women include domestic violence, child abuse and neglect, alcohol and other substance abuse. Mental health proposals cover general issues for Aboriginal Mental Health but also place particular emphasis on Domestic Violence and Mental Health. The NAHS indicates the need for support and services designed and provided by Aboriginal people for Aboriginal people who have been exposed to domestic violence and sexual abuse; and to provide safe houses for those who are victims of domestic violence during the crisis; the employment of Aboriginal people in mainstream domestic violence services; counselling including counselling for families; early intervention strategies; relaxation and behaviour self-management programs; communication and assertiveness training; crisis counselling, to be incorporated into the Aboriginal Health Worker education programs; programs to enable women to form mutual support groups; programs to address the needs of perpetrators.
This Strategy makes the particular point that "most Aboriginal women do not accept this culturally alien non-Aboriginal analysis" of the "feminist/separatist" model, and "do not find it helpful in a crisis".(p174)
The National Aboriginal Mental Health Conference (1993) (Report, Swan and Raphael, 1994) made specific recommendations about the mental health needs of Aboriginal women.
- "That Aboriginal Health Services develop special mental health programs to address:
- Aboriginal Women's Issues ..." (p31)
"That Aboriginal prenatal and postnatal classes be enriched through cultural components by Aboriginal elders" (p31)
- "That young women be given support through programs run by Aboriginal women that promote self-awareness, self-esteem and life realities" (p31)
"That safe places are establ ished for women and children with mental health problems" (p35)
"That Aboriginal women's refuges be resourced to provide for culturally appropriate counselling and mental health problems in their client group" (p36)
The Consultancy Report indicated significant problems faced by Aboriginal women. Those specifically identified included
- Domestic violence - this was identified by the vast majority of those consulted, individuals and organisations, to be a major problem facing Aboriginal women. While it was seen as a problem that must be dealt with by having programs involving men to change their behaviour, it was also seen as critical that services were available for Aboriginal women - e.g. refuges, counselling, to be provided and run by Aboriginal women, and other support and outreach. It was closely linked to problems with alcohol abuse. The adverse effect of the violence on women's health was seen as a problem.
It was considered that shame and cultural issues had encouraged denial and that it was only very recently that this problem was acknowledged in Aboriginal communities.
- Problems for women resulting from sexual abuse in childhood, which were affecting women in adult life, as well as the consequences of neglect, and other forms of abuse, and sexual assault, were all identified as contributing to or constituting mental health problems for women. Specifically it was seen that there were needs for counselling to deal with these problems, services, and support and healing programs for women. There was also an urgent need to prevent further abuse.
- Problems for women who had been separated from their families, by removal and effects for those women and through the generations, of the removal of children were seen as warranting special attention. There was seen the need to be healing programs to deal with these, especially so to do with loss of parenting skills. It was thought that more female children may have been taken initially, to help as domestic servants, and later male children when they were no longer used to the same degree in the pastoral industry. Whatever, all these separations had prolonged and adverse effects.
- High number of young Aboriginal women in Justice Centres – Drug related.
- Young births, young motherhood and associated problems for young women and their babies were identified by some communities. Support programs were seen as necessary, both to deal with the birth and to deal with parenting. Mothers, grandmothers and aunts, and other women should be involved. These were women’s business programs and should be linked to birthing programs to ensure traditional births. They were seen as necessary for all women, but more so for very young women who were likely to be more vulnerable. It was thought that these were very relevant to women's well-being and hence mental health for themselves and their children.
- Post natal depression was indicated to be a problem by a smaller group of those consulted – specifically usually birthing centres or programs. It was felt that there were problems diagnosing post natal depression, as it was often confused with women's distress and separation from families, or capacities to have desired birthing processes, or grief if a baby had died. Nevertheless it was considered to be a real problem affecting Aboriginal women and there was a need for special services to deal with it.
- A Working Group for Aboriginal Women's Mental Health should be established in large communities, linking with Elders, with other women's programs, Women’s Health workers or groups, and the Aboriginal Community Mental Health program for the area or region through the Regional Mental Health Forum. The purpose of this group is to identify Women's needs and the most appropriate programs to enhance their mental health and prevent mental health problems and disorders. Networks, focus groups and action research provide useful models to assist the process, to identify both problems and potential solutions.
- A program core could be developed to deal with
- Violence and Aboriginal Women’s Mental Health. This should incorporate elements of
- education for attitude change
- support groups
- healing programs
- These should be linked to other Mental Health programs for the area.
- Women's Business
- Young women's programs, including self-esteem, education
- Psychosocial care for pregnancy, childbirth and postnatally
- Support, education, parent and related programs for women
- Counselling for women related issues
- Women's roles
- Support network
- Education programs for Aboriginal Women's Health Services and Aboriginal Health Workers and Mental Health Workers should be educated in the area of women's mental health as should all workers working with Aboriginal women. This education should incorporate both prevention and clinical issues (e.g. detection and care of postnatal depression, sexual assault, counselling).
- Data and Information needs
The Working Group should identify needs for data on patterns of mental ill-health and factors contributing for women, and affective interventions to deal with these. The Data and Information Systems Working Party should coordinate national proposals in this area for Aboriginal women, including support for Aboriginal women's well-being to be included in the proposed National Longitudinal Women's Study and the proposed National Mental Health Survey.
- Aboriginal Women's Working Group for Mental Health should be set up in communities with high levels of violence, or high levels of identified women's health issues within one year of implementation of this program area.
- Trial program developments in 2 areas of programs should be set up and evaluated within two years of implementation of this program area.
- Educational programs to ensure knowledge and skills in areas relevant to women's mental health especially psychosocial aspects of care should be established and monitored by the Education and Personnel Development Working Party, within two years of implementation of this program area.
- Data and Information development should inform proposed National Research and Data initiatives for women by end 1995 and set other proposals per priority, e.g. postnatal depression research for Aboriginal women within two years of implementation of this program area. These aspects should be oversighted by the Data and Information Systems Working Party.