Is Best Practice Really Elusive when
working with Indigenous populations?
Dr. Tracy Westerman
Managing Director, Indigenous Psychological Services
SPINZ National Symposium, 2009,
Wellington, NZ
Who am I
Overview of IPS
IPS CORE BUSINESS
Psychological
Assessment
Training
Research
Community
Prevention
Programs
Organisation
Cultural Change &
Development
Brokerage Services
12 Mental Health
specific packages
ADHD
Suicide Prevention
Recruitment &
Retention Services
Forensic, cognitive
& compensation
12 packages
focusing on the
retention of
Indigenous people
Suicide
Prevention
Mediation &
Conflict Resolution
Comprehensive
Audits
4 Indigenous
Specific
Intervention
Indigenous specific
assessment &
intervention
Trauma & Critical
Incident
Development of
Mental Health
operational plans
Anger Management
Parenting skills
Indigenous specific
workforce
development
E-learning
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 Presentation
1.
2.
3.
An overview of the current mental
health status of Aboriginal Australians
Identify the priorities in developing
best practice methodologies in mental
health service delivery for Aboriginal
people
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.
2.
3.
4.
5.
6.
7.
Less likely to access mental health services
Less likely to be identified as having a
mental health problem – by services and
community – “that’s just the way he is”
More likely to engage for shorter periods
and at chronic levels
More likely to be treated with medication
than any other form of therapy
Isolation
and
treatment
access
–
accommodation is greater
External attribution belief system and
problems
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 & Assessments
2. 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-learning
3.
Culture-specific Client Policies and Procedures
4.
Cultural Review of Programs, Tests and Assessments
5.
Cultural Supervision Plans / Mutual Learning
Contracts
6.
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. selfdisclosures; 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 2036
Fax 61 (08) 9362 5546
Email:
ips@ips.iinet.net.au
Website: www.indigenouspsychservices.com.au