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Mullins, Caitlin & Khawaja, Nigar(2018)Non-Indigenous psychologists working with Aboriginal and Torres StraitIslander people: Towards clinical and cultural competence.Australian Psychologist, 53(5), pp. 394-404.

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https://doi.org/10.1111/ap.12338

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https://doi.org/10.1111/ap.12338

CLINICAL AND CULTURAL COMPETENCE 1

Non-Indigenous Psychologists Working with Aboriginal and Torres Strait Islander

People: Towards Clinical and Cultural Competence

Caitlin Mullins and Nigar G. Khawaja

School of Psychology and Counselling

Queensland University of Technology

Running head: Clinical and Cultural Competence

Caitlin Mullins MAPS

Psychologist School of Psychology and Counselling Queensland University of Technology Level 5, O Block, B Wing Victoria Park Road, Kelvin Grove Queensland, 4059, Australia Email: [email protected]

Acknowledgements: The authors would like to thank the participants who gave generously of

their time and knowledge and their Aboriginal and Torres Strait Islander colleagues who

provided advice and input in the planning and execution of the study.


Abstract

Objective: The study explored how non-Indigenous psychologists enact clinical and cultural

competence in their work with Aboriginal and Torres Strait Islander clients, with a particular

focus on client assessment, diagnosis, and interventions. Method: Semi-structured individual

interviews were conducted with twelve non-Indigenous psychologists from across Australia

experienced in working with Aboriginal and Torres Strait Islander people in diverse

geographic and organisational contexts. Results: Thematic analysis of the data revealed five

primary themes associated with the engagement, assessment, diagnosis, intervention, and

management of Aboriginal and Torres Strait Islander clients. Central to the findings was the

need for adaptability and flexibility, a willingness to step outside psychology’s traditional

functions and formalities, the importance of adopting relationship-centred, trauma-informed,

and client-specific approaches, the development of cultural competence as a journey rather

than a destination, and the place for innovative and solutions-focused practice in building the

knowledge and evidence base. Conclusions: This study demonstrates how non-Indigenous

psychologists can adapt their practice to incorporate culturally sensitive approaches when

working with Aboriginal and Torres Strait Islander clients.

Keywords: Aboriginal; cultural competence; Indigenous; mental health; psychological

practice; and social and emotional wellbeing


Key Points

What is already known about this topic:

1. Aboriginal and Torres Strait Islander people experience significant mental health and

wellbeing concerns as a result of unresolved trauma, grief and loss, and cultural

disruption caused by colonisation, past government policies, and ongoing social

injustice.

2. The majority of mental health and wellbeing services for Aboriginal and Torres Strait

Islander people are currently delivered by non-Indigenous practitioners.

3. Promoting the mental health and wellbeing of Aboriginal and Torres Strait Islander

people through improved service delivery is a national priority.

What this paper adds:

1. Articulates how non-Indigenous psychologists can adapt their practice with Aboriginal

and Torres Strait Islander clients to incorporate culturally sensitive approaches.

2. Reiterates the challenges associated with integrating clinical and cultural competencies,

whilst demonstrating how psychologists are attempting to resolve these.

3. Highlights the important role psychologists can play in addressing the Aboriginal and

Torres Strait Islander mental health and wellbeing gap at the individual, family,

community, and societal levels.


Non-Indigenous Psychologists Working with Aboriginal and Torres Strait Islander

People: Towards Clinical and Cultural Competence

Aboriginal and Torres Strait Islander people experience significant mental health and

wellbeing concerns due to the devastating impact of colonisation, past government policies,

and ongoing social injustice. There is a growing acknowledgement of the need for culturally

appropriate interventions that address individual, family, community, and societal factors

contributing to the high levels of distress and mental ill health. There is also a growing

emphasis on preparing a workforce that can work effectively with Aboriginal and Torres

Strait Islander people. Considering that most mental health care is currently provided by non-

Indigenous practitioners, it is important to understand how experienced, non-Indigenous

psychologists adapt their clinical practice to make it more culturally sensitive when working

with Aboriginal and Torres Strait Islander clients.

Aboriginal and Torres Strait Islander people experience frequent significant life

stressors, severe psychological distress, and alarmingly high rates of suicide (Australian

Institute of Health and Welfare [AIHW], 2015). Depression, anxiety, substance abuse, and

psychosis are the most common mental health conditions observed in this population (AIHW,

2015; Parker & Milroy, 2014). The suicide rate for Aboriginal and Torres Strait Islander

people is almost twice the rate for non-Indigenous Australians, rising to five times for those

aged 15-19 years (AIHW, 2015). Unresolved trauma, profound grief and loss, and cultural

disruption caused by colonisation and past government policies has contributed to high rates

of mental health and wellbeing problems (Zubrick et al., 2014). The Aboriginal and Torres

Strait Islander worldview of health and wellbeing is a holistic construct encompassing

physical, emotional, mental, social, cultural, and spiritual health. Colonisation dismantled and

disconnected people from the systems that enabled their survival for thousands of years and


may have helped them cope with and recover from stress, loss, and trauma (Calma, Dudgeon,

& Bray, 2017).

The development of culturally appropriate, comprehensive mental health and

wellbeing services for Aboriginal and Torres Strait Islander people based on the model of

social and emotional wellbeing is a national priority (Australian Government, 2017). Due to

the under-developed Aboriginal and Torres Strait Islander mental health and wellbeing

workforce, the vast majority of services delivered to Aboriginal and Torres Strait Islander

people are provided by non-Indigenous practitioners operating in mainstream settings and

within a Western cultural frame (Kelly, Dudgeon, Gee, & Glaskin, 2010). Concerns have

been raised about the accessibility, acceptability, appropriateness, and quality of mainstream

services (Garvey, 2008; Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe, 2010).

Service delivery tends to focus on responding to crisis (Westerman, 2004) or addressing the

symptoms of trauma such as substance misuse, child abuse and neglect, family and

community violence, and suicide rather than the underlying causes (Dudgeon et al., 2014).

The current system has been described as inadequate and inappropriate, with calls for urgent

changes to be implemented (National Mental Health Commission [NMHC], 2014).

These limitations highlight the need for culturally informed and accepted, clinically

effective mental health and wellbeing services for Aboriginal and Torres Strait Islander

people. Much of the early research guided practitioners toward culturally appropriate

engagement and communication with Aboriginal and Torres Strait Islander people and

communities (Vicary & Bishop, 2005; Westerman, 2004, 2010). More recently, there has

been an emphasis on incorporating cultural identity and exploring cultural factors associated

with psychosocial functioning to ensure the assessment process is fair, accurate, and

appropriate for Aboriginal and Torres Strait Islander clients (Balaratnasingam, Anderson,

Janca, & Lee, 2015; Wand, Eades, & Corr, 2010). The development of tools to support


practitioners to engage Aboriginal and Torres Strait Islander clients in conversations about

mental health and wellbeing issues in a way that honours their cultural understandings

(Balaratnasingam et al., 2015; Dingwall, Puszka, Sweet, & Nagel, 2015), and assessment

instruments that reflect an Aboriginal and Torres Strait Islander worldview of mental health

and wellbeing (Haswell et al., 2010; Schlesinger, Ober, McCarthy, Watson, & Seinen, 2007;

Thomas, Cairney, Gunthorpe, Paradies, & Sayers, 2010; Westerman, 2003), have been

significant achievements in the field. Despite these developments, very few measures specific

to Aboriginal and Torres Strait Islander people have been developed, with most having

undergone only initial validation with limited uptake by the wider psychology profession

(Dingwall & Cairney, 2010; Newton, Day, Gillies, & Fernandez, 2015; Williamson et al.,

2014).

In terms of case formulation and diagnosis, researchers (Kilcullen & Day, 2017;

Parker & Milroy, 2014; Westerman, 2008) have called for Aboriginal and Torres Strait

Islander people to be assessed within their community and cultural context, in the presence of

family members and Aboriginal and Torres Strait Islander mental health workers, and to

consider cultural explanations for their symptoms to reduce problems associated with the

misdiagnosis, under-diagnosis, and over-diagnosis of mental health conditions. Westerman

(2008) has described ‘culture bound syndromes’ specific to Aboriginal and Torres Strait

Islander people that if not understood, may be confused with depression, anxiety, or

psychosis. The knowledge and evidence base about culturally appropriate, clinically effective

interventions for Aboriginal and Torres Strait Islander clients is slowly emerging. The

importance of adopting trauma-informed approaches, guided by an Aboriginal and Torres

Strait Islander worldview, and with a focus on healing and recovery are gaining importance

and are likely to be most effective in improving mental health and wellbeing outcomes for

Aboriginal and Torres Strait Islander people (Atkinson, Nelson, Brooks, Atkinson, & Ryan,


2014; Calma et al., 2017; Dudgeon et al., 2014). Culturally safe and responsive e-mental

health is also emerging as an effective strategy (Dingwall et al., 2015).

Mental health and wellbeing services for Aboriginal and Torres Strait Islander people

must be culturally competent (Walker, Schultz, & Sonn, 2014). Most models of cultural

competence include the interactive elements of awareness, knowledge, and skills, recognise

that the responsibility for developing and practising in culturally competent ways does not

just rest with the individual practitioner but also with the organisations and systems they

practise within, and that it is an ongoing process, not a single event or destination (Walker et

al., 2014). Westerman (2010) described cultural competence as “the ability of practitioners to

identify, intervene and treat mental health complaints in ways that recognise the central role

that culture plays in unwellness” (p.213). According to Westerman (2008, 2010), the

integration of clinical and cultural competencies at the mental health practitioner,

organisation, and system levels is the key to improving service access, utilisation, and client

outcomes. Nevertheless, most practitioners and services often struggle to integrate these two

competing competencies, tending to lean more towards one direction – clinical or cultural –

at the expense of the other.

The psychology profession has a responsibility to develop and support culturally

appropriate, clinically effective, evidence-based ways of working with Aboriginal and Torres

Strait Islander people (Calma et al., 2017; Newton et al. 2015). The work of the Australian

Indigenous Psychology Education Project (AIPEP) highlighted deficits in past education and

training models and has led to the development of a strategic framework and guidelines to

increase the capacity of psychology graduates to provide culturally competent services to

Aboriginal and Torres Strait Islander people (2017). There is a growing consensus that

without a strong knowledge and evidence base to support practitioners in their work,

particularly in relation to conducting culturally appropriate and clinically valid assessments,


ensuring diagnosis of clients is fair and accurate, and delivering interventions in a way that

avoids further traumatisation, reduces distress and suffering, and strengthens holistic health

and wellbeing, the disproportionate rates of mental ill health and suicide and cycles of

intergenerational trauma will continue. There is a need to better understand how non-

Indigenous psychologists, as a key provider of mental health care services for Aboriginal and

Torres Strait Islander people, adapt their clinical practice to incorporate culturally sensitive

approaches to engagement, assessment, diagnosis, intervention, and management when

working with Aboriginal and Torres Strait Islander clients.

A qualitative study conducted by McConnochie, Ranzijn, Hodgson, Nolan, and

Samson (2012) explored the nature of non-Indigenous psychologists engagement with

Aboriginal and Torres Strait Islander clients and attempted to identify strategies perceived as

effective when working in Aboriginal and Torres Strait Islander contexts. The findings

revealed that although psychologists experienced contradictions between Western and

Indigenous ways of working, through a process of trial-and-error they developed strategies to

resolve these differences. Whilst an important initial step in better understanding the work of

non-Indigenous psychologists in this space, the findings primarily discussed issues relating to

client engagement and communication.

This study sought to build on and expand the earlier research by McConnochie et al.

(2012), with a particular focus on client assessment, diagnosis, and interventions. Taking into

account the exploratory nature of the study, a qualitative approach using semi-structured

individual interviews was selected. The aim of the study was to investigate how experienced,

non-Indigenous psychologists enact clinical and cultural competence in their work with

Aboriginal and Torres Strait Islander clients.

Method

Participants


Twelve non-Indigenous psychologists (nine women and three men) registered with

the Australian Health Practitioner Regulation Agency (AHPRA) participated in the study.

Their mean age was 52 years (SD = 12 years; range = 33-72 years). Half of the participants

(6) were based in Queensland, with the remainder in the Northern Territory (2), Western

Australia (2), New South Wales (1), and Victoria (1). Six participants worked in major cities,

with the remaining participants split evenly across regional (3) and remote (3) locations. The

participants were employed in a range of professional contexts including Aboriginal and

Torres Strait Islander specific and mainstream primary health care services, community-

based organisations, schools and universities, and private practice. They worked with clients

across the lifespan in clinical, counselling, health, community, forensic, and research

psychology. Their average years of experience was nine years (SD = 5 years; range = 3-15

years).

Procedure

Ethical clearance was obtained from the university’s human research ethics

committee. Participants were recruited using a purposive sampling. In order to join the study,

participants had to be non-Indigenous registered psychologists with a minimum of three years

experience working with Aboriginal and Torres Strait Islander people. On request, the co-

convenors of the Australian Psychological Society (APS) Aboriginal and Torres Strait

Islander Peoples and Psychology Interest Group disseminated information about the study to

members via email. Those interested in participating in the study were asked to contact the

lead author. Using a snowball procedure, those initially interviewed were asked to identify

other eligible psychologists. These additional participants were approached via email and

invited to express their interest in also being a part of the study.

Each interview was conducted by the lead author, a Caucasian woman with

experience working with Aboriginal and Torres Strait Islander people and communities.


Interviews were conducted either face-to-face or via telephone, following a semi-structured

interview schedule that was provided to participants in advance. Using open ended questions,

participants were asked to comment on the experiences that aided in the development of

cultural competence and the helpful strategies used by them to engage, assess, diagnose, treat,

and manage Aboriginal and Torres Strait Islander clients. The interviews, which ranged

between 44 and 92 minutes, were audio recorded and transcribed. ‘Member checking’ was

incorporated into the study to strengthen the trustworthiness of the data. A written summary

of the themes drawn from each interview was developed and provided to the relevant

participant. Participants were asked to review their summary to check for accuracy of the

content and any interpretations made. The interviews were ceased when the data was

considered to be ‘approaching saturation’, that is, repetition was noted and no new themes

appeared to be emerging.

Method of Analysis

The data was subjected to thematic analysis by the lead author using the six phase

framework outlined by Braun and Clarke (2006). Using NVivo qualitative data analysis

software, initial nodes and sub-nodes were created based upon multiple readings of each

interview transcript, with data from each interview coded to the relevant nodes. Nodes and

sub-nodes were merged, reorganised, and renamed over time to refine the node hierarchy.

The nodes were subsequently organised into overarching themes and sub-themes, informed

by the ‘Ways of Working’ model of engagement proposed by Ranzijn, McConnochie, and

Nolan (2009), and selected partly on the basis of frequency (those mentioned by most

participants) and partly on the basis of uniqueness (those mentioned by one or few

participants but which provided unique insights or interesting points of difference)

(McConnochie et al., 2012). The themes and sub-themes were checked back to the raw

transcripts, written summaries, and node hierarchy by the lead author, allowing for further


refinement. Both authors discussed the preliminary overarching themes and sub-themes and

came to a consensus on the final selection.

Findings

Engagement

Engaging with the community. Being known, accepted, and trusted by the

Aboriginal and Torres Strait Islander community in which one works was described by most

participants as a critical first step in being seen as a helpful resource, particularly for those

working in regional and remote areas. Effective strategies to engage with the community

included introducing oneself to community members and organisations, attending and

helping out at community events, maintaining a visible presence in the community, being

‘vouched’ for by others in the community, and paying respect to local Elders by making time

to meet with them.

[In] one of the communities it was very hard to get to know people and people

weren’t willing to talk to me. Once I’d been introduced to the Elders and I’d … been

given the tick of approval, the next day I had six people knocking on the door.

(Participant 11)

Establishing the context. Almost all participants emphasised the need for flexibility

on the part of the psychologist in establishing the context. Less formal environments were

preferred and where the work setting enabled it, set appointment times were not used.

Participants who worked in regional and remote locations and with people who live more

traditional lifestyles reported being particularly cognisant of the context.

When you have people who are really traditional you can’t just sort of bring them in

and sit them down and sit opposite them and stare at them and talk to them. You

might wanna go for a walk, or you might wanna go for a drive, or you might wanna


sit outside, or if you’re sitting in a room, you might sort of sit at right angles to each

other. (Participant 8)

Where possible, clients were empowered to make the decision about how services

were delivered including the location, timing, methods of communication, and who should be

involved in the sessions. Participants expressed a strong desire to ensure clients felt

comfortable and safe in their interactions with them and that the context supported shared

power between practitioner and client.

I always make sure that I give them lots of different options. I say to them, “Where

would you like to meet up? I can come and see you at school or I can come to your

home or we can meet up in the park … wherever you feel comfortable.” Some people

… feel really comfortable coming in to these clinics … So it really just depends on

the person and I make sure that they make that decision. It’s not my decision.

(Participant 12)

Establishing rapport and building a genuine relationship. Being honest and

transparent about one’s role or service, what psychologists can offer and how they work, and

not making promises were also seen as important by participants. In doing so, clients were

supported to make informed decisions about whether or not they wanted to work with the

practitioner. Taking the time to build a genuine relationship with clients was regarded as very

important by almost all participants. Similar to being known and accepted by the community,

participants reported that unless time and effort was invested in the relationship building

stage, little else could be achieved. The issue of trust was highlighted as critical to the

relationship, with the onus on the psychologist to demonstrate their trustworthiness.

I think in the mainstream view we’re kind of separate and we see people as strangers

most of the time. Within a community, an Aboriginal community, it’s totally the

opposite. People want to know you, know something about you, or get a sense of you


before they’ll trust you. And I think that’s fair enough too … I think it’s important to

take the time to build relationships. (Participant 6)

Effective strategies to build strong working relationships included yarning, sharing

part of one’s own personal story, and allowing the time and space for the relationship to

develop naturally.

Assessment

Defining the problem or issue.

Understanding the client’s worldview. All of the participants spoke about the

Aboriginal and Torres Strait Islander view of health and wellbeing as being holistic in nature,

a concept encompassing physical, mental, emotional, social, cultural, and spiritual aspects

and emphasising the importance of connection to land, family, community, culture, and

spirituality. Illness was understood to be the result of an imbalance between or disconnection

from these elements.

In my work with people, health and wellbeing is quite a broad [concept] …

Connection to land and culture, family and community … And when I hear them talk

about how they feel well, they talk about their spirit. And sometimes they have

another … Aboriginal word for that. But their spirit is well when their connection to

land is good, when they’re living in line with their culture, when their family is going

well, when their community is strong. So when all those things are going well, then

they’re well themselves. (Participant 2)

Participants distinguished between an Aboriginal and Torres Strait Islander

worldview and Western constructs of health and wellbeing which they described as focusing

on the individual and being based on disease or deficit concepts. However, more than half of

the participants reported that for many of the clients they worked with there was a merging of

these ideas depending on the client’s level of acculturation. Understanding the worldview of


each individual client and how they and those in their community understand the problem or

issue was, therefore, deemed to be important to the assessment process.

Understanding the underlying causes and symptoms of distress. All of the

participants identified colonisation – the history of displacement, dispossession, exploitation,

and forced separations and removals – as the original source of the distress experienced by

Aboriginal and Torres Strait Islander people. Intergenerational trauma, profound grief, and

systemic disadvantage were identified as the legacy of these past policies and practices.

Furthermore, half of all participants identified racism as a significant contributing factor to

the ongoing problems facing Aboriginal and Torres Strait Islander people. Racism was

particularly seen to degrade one’s positive sense of self and identity.

The legacy of dispossession and trauma and racism … Our history I think has [had] a

big impact on their wellbeing because it has resulted in their disconnection from

culture and land and community and families. All the things that are important for

Indigenous people we’ve … disconnected [them from] and destroyed. (Participant 4)

Presenting issues such as substance abuse, family and community violence, parenting

difficulties, lack of education and unemployment, mental ill health, and suicide were

understood to be symptoms of the underlying trauma, grief, and disadvantage. As such, most

participants defined the problem or issue in terms of trauma, grief and loss, and chronic stress

and identified a need to address both the underlying causes and symptoms of the client’s

distress.

Developing communication strategies that support information gathering. Most

participants identified the use of culturally sensitive communication strategies as critical to

gathering accurate and rich information about the client and their concerns. Allowing the

story to unfold naturally, accepting silences, waiting for responses, and avoiding direct or


intrusive questioning were identified by participants as specific communication strategies

they used when working with Aboriginal and Torres Strait Islander clients.

With a lot of remote traditional people, you’ll ask something and you may wait five

minutes for an answer. And when you [are] first in that situation you’ll think, “Oh,

they haven’t heard me, I’ll just repeat it.” But, you know, they’ve heard you … When

they’re quiet they’re deciding, “Does she need to know? Am I gonna tell her? Do I

trust her with that information?” (Participant 9)

Most participants reported adjusting their interviewing style so that it felt more like a

conversation rather than a clinical intake interview.

I suppose you could call it a clinical interview but I don’t like to see it that way

because it’s more [of] a chat, getting to know that person and talking to them … [We

have] a chat about who they are, where they come from, what’s going on for them,

which areas of their lives are they struggling [with] or having challenges in, where

their strengths lie … I try to keep away from any clinical [words] or jargon and just

… keep it very casual. (Participant 12)

Deciding on the processes and tools. Participants reported that their assessment of

Aboriginal and Torres Strait Islander clients tended to be broader, with several participants

identifying psychosocial or social determinants of health models as useful approaches to

assessment with this client group. Participants tended to collect information primarily

through conversation or observation. Inclusion of family members was seen as standard

practice, particularly for those working with children or in regional and remote locations.

Most participants noted that the assessment phase typically takes longer with Aboriginal and

Torres Strait Islander clients.

Issues related to limited English language and literacy skills, lack of culturally

validated measures, and possible negative impacts on the relationship between practitioner


and client were identified as barriers to the use of standardised assessment instruments.

Approximately half of the participants reported administering measures verbally, either in

full or a modified format, allowing them to incorporate structured questions into their

conversations with clients whilst overcoming some of the perceived barriers to use.

If you know those tools you can ask exactly the same questions … without all the

jargon and without a form, just through conversation. (Participant 12)

Where standardised instruments were used, short culturally validated measures were

favoured. Participants cited the Westerman Aboriginal Symptom Checklists (WASC-A and

WASC-Y) (Bright, 2012; Westerman, 2003), the Indigenous Risk Impact Screen (IRIS)

(Schlesinger et al., 2007), the Brief Wellbeing Screener (Menzies School of Health Research,

2013), the Kimberley Mums Mood Scale (Kimberley Mums Mood Scale, 2015), and the

Growth and Empowerment Measure (GEM) (Haswell et al., 2010) as examples of culturally

appropriate assessment instruments. Non-culturally specific measures such as the Depression

Anxiety and Stress Scales (DASS) (Lovibond & Lovibond, 1995), the Kessler Psychological

Distress Scales (K-10 and K-5) (ABS, 2012; Kessler et al., 2002), the Strengths and

Difficulties Questionnaire (SDQ) (Goodman, 1997), the Trauma Symptom Inventory (TSI)

(Briere, Elliott, Harris, & Cotman, 1995), the Alcohol Use Disorders Identification Test

(AUDIT) (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), and the Drug Use

Disorders Identification Test (DUDIT) (Berman, Bergman, Palmstierna, & Schlyter, 2005)

were also reported by participants as measures they had used with Aboriginal and Torres

Strait Islander clients, although they were cognisant that they had not been validated for use

with this population.

Diagnosis

In general, participants reported less utility of the DSM-5 or similar diagnostic

manuals in their work with Aboriginal and Torres Strait Islander clients, although the reasons


for this were varied. Approximately half of all participants spoke of their reluctance to use

diagnostic labels, be it with Aboriginal and Torres Strait Islander or non-Indigenous clients,

instead preferring to use the language used by the person to describe their difficulties.

I have never liked putting labels on people. So it’s not just that it’s Indigenous

[clients] here. It’s sort of me as well. I don’t like putting people into boxes.

(Participant 8)

Almost half of the participants noted that their clients’ presentations did not fit neatly

into diagnostic categories. This was partly attributed to the difference between holistic and

disease concepts of health and wellbeing and partly due to the impact of trauma, stress, and

disadvantage on the development of social, emotional, and behavioural difficulties.

The DSM is a disease concept and it’s a mental illness concept … I find that complex

trauma, developmental trauma – which were both rejected [by the] DSM-5 – to be far

more useful concept[s]. (Participant 1)

The issue of cultural validity of clinical diagnostic categories for Aboriginal and

Torres Strait Islander people was also raised as a concern. In particular, one-third of

participants spoke about the risk of confusing ‘culture-bound syndromes’ such as visits from

ancestors with serious mental illness such as psychosis.

I’ve spoken to [people] who see the person that’s passed away and have conversations

with the person who has passed away … In a sense that can be seen as psychosis,

whereas it’s not. It’s part of their culture and its part of their beliefs. (Participant 2)

Even amongst those participants who reported concerns about the issue of diagnosis

with Aboriginal and Torres Strait Islander people, most recognised that diagnostic manuals

and labels can be helpful in particular circumstances. Diagnosis was seen to aid

communication between professionals, inform client treatment and management, alert


practitioners to possible safety risks, and access resources that would otherwise be

unavailable to the client.

Participants reported attempting to resolve concerns about the issue of diagnosis with

Aboriginal and Torres Strait Islander clients by liaising with cultural consultants or

supervisors before making a diagnosis, describing the client’s experience in terms of

symptoms and behaviours rather than assigning a label, and refraining from making

diagnoses of personality disorders due to the high incidence of these disorders amongst

people affected by trauma. One participant reported that becoming more aware of their

personal values and practice framework had helped them to determine when the use of

diagnosis was warranted.

I come from a place of social justice and recovery and social emotional wellbeing …

so I’m probably not too much into labels … But I might be interested to help clarify

[something] for myself … So look at your values, look at your framework and then

decide what your relationship to the DSM is … And recognise that it's a tool. It's one

tool. It's actually pretty valuable as a tool but it is ultimately just a tool. (Participant 7)

Intervention

Promoting safety and stability. Half of the participants identified the need to assist

clients to restore a sense of safety and stability in their lives through the development of

emotional regulation, distress tolerance and mindfulness skills, or by providing practical

support and advocacy to address immediate concerns such as homelessness or an untreated

health condition.

I mean I could be her psychologist and just focus on her PTSD … but her biggest

issue really is that she’s homeless and that she needs to get a house. And so, a lot of

my … effort [has gone into that. But whilst] all that's happening [we] are having


conversations and I’m assessing how bad are her PTSD symptoms? How’s her level

of depression or suicidality? (Participant 4)

Safety and stability was also promoted through the development of a safe, trusting,

attuned relationship between practitioner and client. Helping clients to feel safe in

relationships was identified as critical, particularly for those practitioners who worked

primarily with clients affected by interpersonal trauma, abuse, and neglect.

Whatever model you use it’s still primarily a person [who] has a lot of difficulty in

relationships … However you come at it, it’s about [the] relationship and it’s about

finding a safe relationship in which you can work through some other stuff.

(Participant 1)

Utilising contemporary therapeutic approaches. Participants were split regarding

the appropriateness of cognitive behavioural therapy (CBT) with Aboriginal and Torres Strait

Islander clients. Several participants reported that they did not believe CBT was appropriate

for this client group, in particular raising concerns about the technique of cognitive

restructuring.

I certainly wouldn’t do standard CBT. I wouldn’t challenge people on their thinking

and say, “Well, actually, the way you think determines how you feel. And how you

feel makes you behave in a certain way.” (Participant 8)

In contrast, almost half of all participants stated that they believed elements of CBT

could be utilised if adapted to be more culturally and contextually appropriate and

individualised to the client. Modifying the language and concepts to be more relatable, gently

exploring the helpfulness of certain thoughts in one’s life, considering alternative options

without directly challenging the client, and encouraging the development of practical skills

such as goal setting and problem solving were identified as helpful adaptations.


I try to follow people’s preferences so if they were talking in ways that fit with CBT,

and occasionally they do, I might share some CBT ideas with them. (Participant 6)

Almost half of all participants identified narrative therapy as an effective therapeutic

intervention with Aboriginal and Torres Strait Islander clients. The process of exploring and

re-authoring the stories of one’s life, challenging dominant discourses, and externalising the

problem were seen to be particularly relevant to the client group. Several participants

reported that this was their preferred therapeutic approach, with the remainder reporting that

they incorporated elements of narrative therapy in their work with Aboriginal and Torres

Strait Islander clients.

I think it takes into account the … holistic approach, [it] embraces the idea of people

living within [a] family, within [a] community … [the] surrounding factors that play a

role in how people live their life. It welcomes the big picture rather than focuses on

the individual which I feel fits with the Aboriginal and Torres Strait Islander way of

being. (Participant 2)

Other therapeutic interventions identified by participants included psychoeducation,

motivational interviewing, acceptance and commitment therapy, solution focused brief

therapy, psychodynamic therapy, schema therapy, family therapy and parenting interventions,

behavioural therapy, and psychodrama. A number of participants identified recent

developments in attachment, neurobiology, and somatic approaches as showing potential

benefit in their work with Aboriginal and Torres Strait Islander clients.

All participants reported incorporating elements of different therapeutic modalities

dependent upon their own preferences and the client’s presenting concerns or preferences. In

general, it was not so much the particular therapeutic approach utilised as it was the quality of

the relationship between practitioner and client and adapting the approach to the individual

and their context that was seen as key.


I think if you build up the relationship and you use language that people can

understand, I’d say most approaches will work. (Participant 2)

Valuing cultural healing traditions. One third of participants, all from regional and

remote locations, acknowledged the importance of cultural healing traditions to their

Aboriginal and Torres Strait Islander clients. Participants spoke of the significance of

accessing traditional healers, being on country, or participating in cultural healing programs

for their clients’ sense of wellbeing and cultural resilience. In general, practitioners

considered that these healing traditions should be managed by the community, with their role

to simply be open to and supportive of clients accessing them.

[I] work alongside people in the community that [provide] cultural healing … It’s not

something I’d be directly [involved] with because of cultural protocols … I think that

probably the biggest part is being open to people's cultural and spiritual views.

(Participant 6)

Contributing to social and political change. Most participants spoke of the wider

role psychologists can play in creating an environment for recovery and healing by

advocating for social and political change. Autonomy, community control, and self-

determination were identified by most participants as important for Aboriginal and Torres

Strait Islander people and communities to recover and heal from distress. Participants

identified celebrating Aboriginal and Torres Strait Islander cultures and people, challenging

racism and discrimination, advocating for changes to government and mainstream services’

policies and practices, supporting community-led responses to issues, and supporting the

development of an Aboriginal and Torres Strait Islander mental health and wellbeing

workforce as ways in which they contribute to social and political change. They did,

however, acknowledge that this required a willingness to step outside of what is traditionally

considered the role of a psychologist.


Management

Collaborating with other professionals. The majority of participants worked in

multi-disciplinary settings, allowing them to work in partnership with other professionals to

address their clients’ health, housing, education, employment, income support, justice, and

child protection concerns. The ability to provide a holistic response was identified by most

participants as a benefit to working collaboratively with others.

What I can do is get [other] people involved and actually try and build … a team

approach to supporting that person … Multi-disciplinary people all working together

to support that person [and meet] their needs. (Participant 12)

In some settings, Aboriginal and Torres Strait Islander staff were partnered with non-

Indigenous practitioners and worked collaboratively to deliver the service.

We often work in twos. A client will get allocated to me and an Aboriginal worker …

In that way we can sort of sit down together and do an assessment or the Aboriginal

worker might introduce herself to start with and then bring me in later. (Participant 8)

Evaluating outcomes. Seeking feedback from clients and others involved in their

lives in a purposeful way was the most common method of evaluating client outcomes

reported by participants. This was closely followed by observing clients in their natural

environment and seeking evidence of improved social, emotional, and behavioural

functioning.

[If you have that] rapport with the family, you [can] ask them, “How are you

travelling? How are going? How do you feel like things are progressing?” And they’ll

tell it to you straight up. If they [are] still having issues, you’ll hear about it and if

things are settling down, then you’ll observe that as well. (Participant 12)

Where practitioners had previously administered standardised assessment

instruments, the same measures were used to track progress over time. Only one participant


reported considering trialling formal feedback informed treatment (FIT) methods such as the

Outcome Rating Scale and Session Rating Scale (Miller & Bragmann, 2012), however, had

not yet utilised them in their work with Aboriginal and Torres Strait Islander clients. Despite

the lack of formal outcome measurement processes or tools, most participants acknowledged

the importance of seeking feedback and measuring change to inform the therapeutic process.

Discussion

Key Emerging Themes

Consistent with earlier studies investigating the experiences of psychologists working

with Aboriginal and Torres Strait Islander people or in rural and remote settings

(McConnochie et al., 2012; O’Connor, Chur-Hansen, & Turnbull, 2015; Sutherland & Chur-

Hansen, 2014; Vicary & Bishop, 2005), flexibility, adaptability, and a willingness to step

outside the bounds of psychology’s traditional functions and formalities were seen as

essential practitioner qualities. Participants articulated how they adapted their approach to

account for cultural and contextual differences and to resolve the contradictions between

Aboriginal and Torres Strait Islander and mainstream ways of working. These qualities

appeared to be not so much learned techniques but rather personal attributes and preferences

of the practitioner and likely contributed to their attraction to, and suitability for, work with

this client group.

In line with previous studies (Bennett, Zubrzycki, & Bacon, 2011; O’Connor et al.,

2015), the findings reinforced the importance of relationships with individual clients, their

family, the wider community, local Elders, and colleagues when working with Aboriginal

and Torres Strait Islander people. Relationships can be developed through effective

engagement strategies but ongoing attention and effort must be paid to ensure they remain

strong. Trust, respect, honesty, collaboration, and safety were seen as fundamental to good


relationships between non-Indigenous psychologists and Aboriginal and Torres Strait

Islander people.

The findings reiterated the challenges associated with integrating clinical and cultural

competencies, particularly in terms of client assessment and diagnosis. However, this study

also demonstrated ways in which non-Indigenous psychologists are attempting to resolve

these issues. Non-Indigenous psychologists reported incorporating assessment tools

specifically developed or adapted for use with Aboriginal and Torres Strait Islander people in

their day-to-day practice with clients. Consistent with the recent emphasis on assessment

(Dingwall & Cairney, 2010; Newton et al., 2015; Williamson et al., 2014), the findings

indicated practitioners’ willingness to experiment with what is available to ascertain if it can

be adapted to be more suitable and appropriate for use with this client group. Likewise, whilst

participants reportedly consulted the DSM-5 and similar diagnostic manuals to guide their

thinking, they were not constrained by these clinical tools, instead considering cultural

explanations for the client’s presenting problems and alternative diagnoses such as

developmental or complex trauma. These findings suggest practitioners are open to new and

innovative ideas and actively seek solutions to gaps in the existing knowledge and evidence

base.

The need to understand the nature and impact of historical, intergenerational, and

present-day trauma on Aboriginal and Torres Strait Islander people and the value of adopting

trauma-informed approaches to address these issues emerged as significant themes in the

findings (Atkinson et al., 2014; Dudgeon et al., 2014). Fostering safety and trust in the

context of the practitioner-client relationship, enabling client control and shared power,

assisting clients to restore a sense of safety and stability in their lives, and promoting client

strengths were viewed as crucial for recovery and healing. Working as a trauma-informed

practitioner did not necessarily mean that clients were encouraged to re-visit or process their


traumatic memories or experiences. Rather, it provided a framework for the safe engagement

of clients in the therapeutic process, provided a lens through which the client’s presentation

and concerns could be understood, and helped to focus the intervention on improving the

client’s quality of life and psychosocial functioning. These findings provide a unique

contribution to the knowledge base by describing how non-Indigenous psychologists

incorporate trauma-informed approaches in their work with Aboriginal and Torres Strait

Islander clients.

The findings also demonstrated the varied interventions and multitude of roles non-

Indigenous psychologists undertake in their work with Aboriginal and Torres Strait Islander

clients. The contrasting opinions about the appropriateness of particular therapeutic

approaches are reflective of recent debate in the literature (Bennett-Levy et al., 2014,

Dudgeon & Kelly, 2014; Nelson et al., 2014). The statement that “most approaches will

work” if they are adapted for use with Aboriginal and Torres Strait Islander people is

interesting and suggests that rather than asking if a particular approach is effective, the

question should be what approaches, with whom, in what situations, and for which types of

mental health and wellbeing problems, works best. In contrast to the article by McConnochie

et al. (2012), this study found that non-Indigenous psychologists believed that a critical part

of their role was to advocate and agitate for political and social change, in addition to

providing culturally appropriate, clinically effective, evidence-based therapeutic

interventions. The role of psychologists as agents of social and political change did not

emerge in the earlier study. It is unclear if these findings represent a shift in thinking within

the profession or are simply the result of different participants and interview questions.

Finally, the findings were a reminder that rather than comprising separate and distinct

elements, cultural competency involves a dynamic interaction between cultural knowledge,

awareness of one’s values, beliefs, and attitudes, and generalist and specialist skills (Ranzijn


et al., 2009), and is demonstrated throughout the therapeutic process. Developing cultural

competency was described as an ongoing journey and that regardless of the number of years

one has worked with Aboriginal and Torres Strait Islander people, it is a journey that does

not, and perhaps should not, have an end point.

Limitations and Future Directions

Whilst the aim of this study was to explore the experiences of non-Indigenous

psychologists and understand how they adapt their clinical practice to be more culturally

sensitive, the next logical step is to test if the approaches described here would be endorsed

as culturally appropriate by Aboriginal and Torres Strait Islander mental health professionals

and clients. Further, the current findings cannot confirm the effectiveness of the clinical

practices utilised by non-Indigenous psychologists, highlighting the need for further research

to develop the knowledge and evidence base. Despite a diverse mix of participants, the

sample size was still relatively small. A larger sample size with a mix of participants along

gender, age, professional setting, and geographic location would allow for more detailed

analyses to be conducted. Although there seems to be a number of similarities in the way

practitioners approach their work with Aboriginal and Torres Strait Islander clients, the wide

diversity within and between Aboriginal and Torres Strait Islander communities means that

the experiences described here may not be appropriate with all clients and communities and,

as such, the generalisability of the findings should be considered with caution.

Implications

The implications of the mental health reform agenda (NMHC, 2014) and the work of

the AIPEP (2017) for current and future psychologists working with Aboriginal and Torres

Strait Islander people, and the profession as a whole, are significant. Together with the

recently released National Strategic Framework for Aboriginal and Torres Strait Islander

Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023 (Australian


Government, 2017), these initiatives point to the urgent need to support the development of a

culturally competent workforce comprised of Aboriginal and Torres Strait Islander and non-

Indigenous practitioners through the inclusion of appropriate learning experiences for

undergraduate and postgraduate students and professional development opportunities for

those already working in the field. They also highlight the need for further research to guide

the development of culturally appropriate, clinically effective, evidence-based screening and

assessment instruments, therapeutic interventions, and outcome measures.

Conclusions

The direct practice experiences of non-Indigenous psychologists experienced in

working with Aboriginal and Torres Strait Islander people contributes an important

perspective to this field of research. Capturing real-world practice examples provides

guidance to less experienced practitioners, helps to build the growing knowledge and

evidence base about Aboriginal and Torres Strait Islander mental health and wellbeing

service delivery, and highlights opportunities for further research and sector development.


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