Is Best Practice Really Elusive when working with Indigenous

populations?

Dr. Tracy Westerman Managing Director, Indigenous Psychological ServicesSPINZ National Symposium, 2009,Wellington, NZ

Who am IWho am I

Overview of IPS

IPS CORE BUSINESS

Psychological Assessment

Training Research

ADHD

Community Prevention Programs

Organisation Cultural Change & Development

Brokerage Services

12 Mental Health specific packages

12 packages focusing on the

retention of Indigenous people

4 Indigenous Specific

Intervention

SuicidePrevention

Suicide Prevention

Mediation & Conflict Resolution

Trauma & Critical Incident

E-learningAnger

Management Parenting skills

Recruitment & Retention Services

Comprehensive Audits

Development of Mental Health

operational plans

Indigenous specific workforce

development

Forensic, cognitive & compensation

Indigenous specific

assessment & intervention

A few dilemmas to highlight the problems with mainstream

approaches to suicide prevention• A traditional Aboriginal Australian is

charged with the statutory assault of a 12 year old girl from an Aboriginal community – he is sentenced to two months in prison on the basis that he argues that the girl was ‘promised’ to him as part of a traditional marriage. The girl goes on to attempt suicide

• Abuse or Culture?

And Mainstream approaches to Mental Health

• An Aboriginal man is on trial for the murder of his traditional wife. He says that on the days leading up to the event he was being ‘sung’ (cursed) by cultural law men. The singing involved command hallucinations. He has no history of violent behavior.

• Psychotic or culture-bound?

Overview of Presentation1. An overview of the current mental

health status of Aboriginal Australians2. Identify the priorities in developing

best practice methodologies in mental health service delivery for Aboriginal people

3. The work of IPS in developing models of effective practice in Indigenous mental health (and suicide prevention)

The State of Play

• Misdiagnosis, overdiagnosis and underdiagnosis of mental health issues

1. Cultural Triggers not identified in mainstream assessments – but can we measure the relevance of culture?

2. Practitioner impacts – judging the absence or presence of disorder

3. Normality seen as abnormality – e.g. being sung/cursed, having spiritual visits of deceased loved ones versus psychosis (culture-bound syndromes)

What the current day looks like….

1. Less likely to access mental health services

2. Less likely to be identified as having a mental health problem – by services and community – “that’s just the way he is”

3. More likely to engage for shorter periods and at chronic levels

4. More likely to be treated with medication than any other form of therapy

5. Isolation and treatment access – accommodation is greater

6. External attribution belief system and problems

7. Stigma regarding mental health

What role history has played…• Population of over 1 million prior to 1788,

declined to 30,000 by the 1930’s• Social policies

• Assimilation until 1972• Exclusion from education until 1960’s• Exclusion from parenting support benefits until

1970s• Citizenship rights in 1960’s• Classified under flora and fauna until 1960’s• Prohibition until the 1970s

And continues to play…..• Aboriginal people constitute 2.2% of the

Australian population of approx 20 million • Most disadvantaged on every social

indicator• Life expectancy 20 years less than NA

(average is mid 50)• Infant mortality is three times that of NA

Australia• Fourth world conditions• Denial of History (refusal to say sorry) under

Howard Liberal Govt from 1996 - 2007• Validation of trauma – why ‘sorry’ was not

the hardest word after all• How this maintained trauma and difficulty

in healing

Impacts of Stolen Generations• Acculturative stress and marginalisation• Premature death and compounded grief• Forcible removal – loss of parental

models and practices • Cultural parenting strategies are seen

as deficient by mainstream• Removal leads to difficulty in

developing healthy attachments• Ability to respond to the range of

positive and negative emotions in our own children

Impacts of Stolen Generations• Intergenerational Impacts

• Mental illness and genetics/environment • More likely to experience intra-familial

abuse leading to greater risk for PTSD and difficulty with healing

• Changes to cultural practices• The role of payback (customary law) in

dealing with non-traditional issues (i.e. assault and suicides)

• Sorry time and cultural grieving for suicide

How this translates

• Rates of mental ill health• suicidal behaviours,• depression, • self-harm, • PTSD???• Dual diagnosis - alcohol and drug

useage

What are the priorities in

Aboriginal mental health?

Priority 1: Reliable and Valid Assessments & Tests

• Impacting on • Are the assessments culturally valid?

Construct? Face? Cultural?• Does the assessment take into account

the cultural relativity of behaviour? E.g of ADHD; spiritual visits

• Evidence for trends in tests with minority populations e,g. Depression measures; MMPI; CBCL

• Different symptom base for disorders across cultures (Westerman, 2003; Allen, 1998; Manson, 1995)

Priority 2: Improving on access to appropriate services• Cultural Competence is ill defined

and not measurable becoming the ‘poor cousin’ to clinical competence• Leads to Organisations grappling with

how to embed cultural competence in all aspects of service delivery

• No clear pre requisite skills in working with Aboriginal people in a mental health capacity

Problem: Inequities in research and Indigenous specific mental health

intervention programs• Prevalence rates range from 1.8%, to 51.2%• Limited prevalence data and lack of

representation of Aboriginal people in epidemiological studies

• Research always suggests a mainstream view of risk, resilience and aetiology

• No published research into the efficacy of traditional treatments, mainstream counselling, therapies or intervention programs with Aboriginal people

• Predominant “Absence of Evidence” view in relation to the existence of culture-bound syndromes

The role of IPS in finding some solutions…..

Solution: Development of Unique Tests & Assessments

1. The Westerman Aboriginal Symptom Checklist - Youth (WASC-Y: Westerman, 2003) and WASC-A, resulting in:

• Identify early stage of risk• Population level data specific to

Aboriginal people on the nature of suicide

• Valid prevalence data• Information on co-occurrence of

disorder• Able to evaluate efficacy of

intervention

Unique Tests & Assessments2. Aboriginal Mental Health Cultural

Assessment Models (Westerman, 2003) to enable diagnostic formulation across major disorders – spiritual visits or being sung; sorry cuts; longing for country

3. Acculturative Stress Scale for Aboriginal Australians (Westerman, 2003)

• Relationship with risk –15% of variance for psychological symptoms accounted for by culture stress

• Mental health outcome. The focus is on reducing culture stress

Unique Tests & Assessments

4. The Acculturation Scale for Aboriginal Australians (Westerman, 2003)• Provides cultural evidence for disorder – e.g.

command automatism; possession psychosis etc., so that ethnic or racial heritage is concretised rather than an amorphous construct (Tseng, Matthews & Elwyn, 2004; Diamond, 1978)

• Gauges the extent of connection with culture / beliefs relative to other Aboriginal people (Westerman, 2003)

• Forces practitioners to explore a cultural basis for all illness

• Addresses the issue of test bias• Community then provides collateral

information to support assessment/diagnosis

Solution: Workforce and Organisational Cultural Competencies

• Determined the predictors of cultural competence via the Aboriginal Mental Health Cultural Competency Test (CCT: Westerman, 2003, 2009 in prep)• Knowledge• Beliefs and Attitudes• Skills & Abilities• Resources and Linkages• Organisational Cultural Competencies

• Objective, measurable over time and compared with national norms

Workforce and Organisational Cultural Competencies

Tied in with comprehensive cultural intervention including:

1. Indigenous Specific Mental Health Training – 24 packages; 8,861 people trained since 2000

2. E-learning3. Culture-specific Client Policies and Procedures4. Cultural Review of Programs, Tests and

Assessments5. Cultural Supervision Plans / Mutual Learning

Contracts6. Development of Indigenous Mental Health Service

Delivery Models in which SP’s need to attain a ‘black card’ of cultural competence and community then oversee the ongoing delivery of the program

Solution: Culturally Driven and Valid Research

• Evidence based practice for disorders via population level data – e.g. of Aboriginal suicide

• Validation of CB syndromes• Adaptation of Counselling Micro-skills - e.g. self-

disclosures; gratuitous concurrence• Adapt therapies to incorporate cultural

differences in learning styles – visual memory• Determine the role of mainstream therapies in

treating CB syndromes e.g. longing for country• Validation of traditional treatment hierarchy• Cultural evidence for organisational policies

relative to cultural norms e.g. second/third hand referrals/cultural vouching for engagement

Solution: Developing Community Capacity – whole of community suicide

intervention programs• Demand for forums from community • Unique content • Three different groups – SP’s, community & youth• Training for SP’s and psycho-education for youth

& service providers• Outcome driven evaluations demonstrating

consistently statistically significant increases focusing on:

• Skills increases• Knowledge• Intentions to assist

• High risk regions and potential for risk targeted• 8 regions since July, 2002 delivered over 3

phases• Over 1,800 trained – 85% Indigenous

Where to from here?

• We need to continue to improve diagnosis, prognosis and intervention

• Replicate models for use with other presenting issues

• Transferability across different groups• Longitudinal data to determine impacts• Ensure that cultural competency becomes

a minimum standard• Continue to facilitate community

development of unique programs, models and services which challenge mainstream constructs of mental health

Contact Details.

Indigenous Psychological Services

PO Box 1198 East Victoria Park WA 9681 Phone 61 (08) 9362 2036Fax 61 (08) 9362 5546Email:ips@ips.iinet.net.auWebsite:

www.indigenouspsychservices.com.au