Psychological Tools for Aboriginal People: How can these be of assistance?

1. Psychological Tools for Aboriginal People: How can these be of assistance? Dr. Tracy Westerman Managing Director Indigenous Psychological Services Post-Doctoral Research Fellow, NH&MRC, Curtin University of Technology, WA

2. Indigenous Psychological Services

3. What do we know about Aboriginal disadvantage • Rates of mental ill health in Australia - depression, anxiety, self-harm, suicidal behaviours • Post-traumatic stress • Compounded grief and trauma • Intergenerational effects of posttrauma • Death attributable to external causes • Data from Kids Helpline - 35% of calls regarding current abuse • Alcohol and drug useage

4. Why?Identify the inequity to define priorities Priority 1: Mental Health Assessment • Misdiagnosis, overdiagnosis and underdiagnosis • Adequacy of methods of assessment in use • Reliability and validity • Different symptom base for disorders within and across cultures (Westerman, 2003; Allen, 1998; Manson, 1995) • Cultural Triggers not identified in mainstream assessment protocols • Cultural Differences seen as deficits • Normality seen as abnormality, e.g. self-harm; psychosis • Prevalence of mental disorders range from 1.8%, to as high as 51.2% • Compromises funding and mental health priority areas based on prevalence of disorder

5. Identify the inequity to define priorities Priority 2: Research • Quality versus quantity research • Empirically validated models – therapy, traditional treatments and community based interventions • The ‘absence of evidence’ argument • Nothing is evaluated Priority 3: Diagnosis and assessment • Indigenous risk factors: Is there a different aetiology? • Mainstream factors at a higher rate, and/or unique risk factors that create a heightened risk. • Does the behaviour result in impairment across environments and cultural contexts • Differential cultural diagnosis e.g. ADHD and being ‘sung’ • Differential clinical diagnosis (e.g. FAS, PTSD)

6. Identifying Priorities Priority 4: Service Type • Lack of focus across the broad spectrum of mental health programs • Most services are diversionary and reactive in nature rather than preventative • Limited programs that target indigenous specific risk factors Priority 5: Access to mental health services • More likely to engage for shorter periods and at more chronic levels • Lack of access by Aboriginal people to secondary / tertiary services Priority 6: Treatment Efficacy • The “nothing works” argument • Medication rates • Traditional Treatments - the absence of evidence argument • Comorbidity - identification, diagnosis and prognosis • Aboriginal people seek cultural reasons and solutions prior to any other treatment • External attribution belief system and problems

7. Identifying Priorities Priority 7: Workforce Issues Lack of culturally and clinically appropriate services for Aboriginal clients • Less than half of all non-Aboriginal practitioners feel culturally competent with Aboriginal people • Less than half of all Aboriginal practitioners feel clinically competent with Aboriginal clients • Limited training regarding ‘what works’ with Aboriginal clients • Therapies • Counselling • Traditional and Westernised Methods of Treatment • The Dual Struggle

8. The Dual Struggle The Dual Struggle in the provision of services to Aboriginal mental health clients (Vicary & Westerman, 2002). Clinical and CulturalCompetence Cultural Competence Clinical Competence

9. Identifying Priorities • The Dual Struggle becomes an inequitable struggle • Ambiguity regarding cultural competence • Results in workforce being solely defined against clinical not cultural expertise

10. What has been done to address escalating rates of mental ill health? • The use of mainstream assessment protocols • The delivery of mainstream programs • lack of access by Aboriginal people • ad hoc, not evidenced based or empirically validated, replicated or evaluated • The evidence for early intervention approaches in NA communities • Friends, Aussie Optimism, RAP, Triple-P

11. The role of IPS • A range of training, clinical and research services • Primary services in over-supply • Motivated by the “nothing works” argument • Strengths / differences approach rather than deficits - e.g. Parenting differences, not parenting problems • Westernised & traditional treatments combined

12. Solutions to inequities in effective mental health service delivery Solution 1: Ongoing Quality Research Understanding indigenous specific risk factors in mental health • Impact of child-rearing practices and cultural differences • Population versus individual level risk – what accounts for high rates of mental ill health? • Mainstream risk factors - but at a greater level • Are there predominant symptoms that define the Aboriginal • Are there cultural explanations for disorders? • Are there cultural variants to symptoms • Cultural resilience as a moderator of illness • Determining Treatment Efficacy • Traditional and westernised treatments • Articulating what is different • E.g. the Engagement Model

13. Development of a unique screening tool Westerman Aboriginal Symptom Checklist - Youth: WASC-Y • Determined differences in how mental illness is conceptualised • Explored symptomvariation across disorders • Population level risk • Reliable and Valid • FA: 5 clear factors (34-88% of variance) • Alpha of .85 - .90; kappa of 0.84 • Over 600 youth screened across Australia • Validation studies – QLD, NSW and NT • WASC-A • Cultural and Clinical Validation of disorder • Evaluate client outcome relative to cultural triggers, maintaining factors • Range of prevalance data, including comorbidity data

14. Solution 2: Increasing Treatment Efficacy 2. A. Development of information regarding the existence of CB disorders • Cultural Validation – when is something CB and when it is mental ill health? • Motivated by the absence of evidence argument 1. Being ‘Sung’ or Cursed by an aggrieved party 2. ‘Sorry time’ or Self-Harm 3. Psychosis or spiritual visits 4. Depression or longing for, crying or being ‘sick’ for country

15. Increasing Treatment Efficacy B. Targetting cultural triggers in treatment interventions C. Working within the traditional hierarchy of Treatment Intervention • treatments are hierarchically organised depending on cause, severity, type of practitioner required and treatment D. Increasing the cultural relevance of existing mainstream therapeutic approaches

16. Increasing Treatment Efficacy • The “nothing works” with Aboriginal people argument • Blame the client • Framework is a strengths (understanding and incorporating cultural differences) rather than a deficit approach - how can we take advantage of the strengths that Aboriginal people have? • CBT • Narrative and external attribution belief systems • Basic Counselling Skills

17. Solution 3: Increasing Workforce Skills • Defining workforce and services on the basis of cultural competence • Cultural Competence Continuum (Westerman, 2003) • The 7 Levels of Cultural Competence • At the practitioner and organizational levels • Definable, measurable and ongoing • Baseline of skills • Some strategies that have been used: • Engaging in Cultural supervision • Taking referrals second and third hand (traditional way)

18. Solution 4: Developing Indigenous Specific Training Packages • Development of Indigenous specific training packages • In last 12 months IPS have trained 1,023 service providers and 167 community and 90 youth through Australia (75% Aboriginal). • Developed from within the Aboriginal culture • Incorporates indigenous worldview, risk and protective factors • 17 different packages

19. Solution 5: Increasing levels of access to mental health services by developing Community Capacity: The statewide suicide forums Brief Overview: • Three introductory, two Advanced Skills and One Skills Consolidation Forum have been held since July, 2002 at three primary locations in the West Kimberley, North West and Goldfields. • Forums have been well attended with a total of 385 people attending the workshops: • A total of 94 community members • A total of 185 service providers • 106 youth. • 82% of participants identified as Aboriginal • All participants either worked with suicidal clients, had personal experience of a family or friend who had engaged in suicidal behaviours or expressed a desire to assist in preventing the high levels of Aboriginal youth suicide.

20. How Indigenous specific information can be of benefit? • Demand for forums from community • Content was specific to context • Community Development approach - youth, community and service providers • Developed specifically for Aboriginal people • Introductory, Follow-Up and Counselling Support • High risk regions and potential for risk

21. Statewide Suicide Prevention Forums • Outcome Driven Evaluations • Levels of confidence in referring people to a local services • Intentions to Help • Suicide and Depression Knowledge • Increase in Skills • Pre and post test of youth symptoms over time • Youth trained in suicide prevention as well as psychoeducational approach – assuming risk

22. The evidence for developing community capacity • The Family Well-Being personal empowerment course implemented in Alice Springs between March 1998 and April 1999 • to build parenting and relationship skills. • The Yarrabah Family Life Promotion program • initiated following a suicide epidemic in the period mid 1980’s to mid 1990s. • involved training and employment of local people as Family Life Promotion officers who received support from visiting mental health professionals. • resulted reduction of self harm by the mid late 1990's, and there were no suicides in Yarrabah in 1997 and 1998. • The NSW experience – addressing family violence

23. Evaluation Data • Community and Service Providers • Significant shifts across knowledge, skills, intentions to help behaviours and competencies and pre and post training levels • Statistically significant increases at follow-up and Skills Consolidation • Skills Competencies • Training Competencies • Barriers to Help Seeking Behaviours • Youth • Shifts in symptoms at follow-up • Anecdotal reports

24. Results Levels of confidence in referring people to appropriate local services

25. Results Improvement in knowledge of depression and suicide after the forum

26. Results Improvement in skill levels after the forum

27. Results Improvements in participants intention to help

28. What will happen? • Tracking of skills retention and behavioural change over time • Development of community support networks in times of crisis, anniversary’s, birthdays • To provide greater levels of access to remote communities who requested that the training be delivered on a “community wide” basis (e.g., the whole community undertake the training) • To conduct random samples of risk within the youth cohort over time • To focus on other regions expressing interest – within the limitations of funding

29. Developing an Indicated Intervention Program for Aboriginal youth at risk • Healthway funding for 2003 – 2006. • Indigenous specific risk factors as opposed to mainstream risk factors • Development of an Intervention Program which is sustainable through training of AIEO’s and Psychologists in the PED • To evaluate symptom change over time using the WASC-Y

30. Addressing broader risk across Aboriginal people - what is stopping us? • Empirical & Cultural Validation of Treatment Interventions and Models of ‘Best Practice’ which are: • Able to be replicated for use with other issues • Transferability across different groups • Demonstrate long-term outcomes • Are sustainable • Programs are developed that rely on funding and external support rather than ‘community capacity’ • Access to service providers to deliver culturally and clinically valid programs • Studies show success of programs depend on community self-management and ownership

31. How to Contact Us Indigenous Psychological Services Suite 3, 20 Twickenham Street, Burswood, WA (08) 9362 2036 ips@ips.iinet.net.au www.indigenouspsychservices.com.au