Measurement of Mental Health Problems in Aboriginal and Torres Strait Islander Populations

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Measurement of Mental Health Problems in
Aboriginal and Torres Strait Islander
Populations

• Understanding the effect of bias in assessing
  Aboriginal people Reviewing current practice to
  determine culturally valid assessment processes
• By
• Tracy Westerman, Director
• Indigenous Psychological Services

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Project Need Sources of bias in assessment

• Mental health outcome measures have been used
  extensively within clinical practice to measure
  the extent of change (with symptoms, social
  cohesion, independence) which can be attributable
  to interventions.
• Mental health of indigenous groups
• Rates of suicide, depression, anxiety.
• Methods of assessment currently used
• unreliable
• different methods used within and across studies
• NMHP and confusion regarding measurement of
  mental ill health and mental health outcomes
• Problems with equity in service delivery.

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How this affects service delivery and equity in
access to quality services

• Culturally biased assessment considered as a
  barrier to determining effective outcomes and
  interventions
• Has the assessment identified all possible
  factors associated with the development and
  maintenance of disorder?
• Are assessments a valid indication of the clients
  true functioning (cultural impairment)?
• Does the assessment provide information of
  cultural relevance that impacts upon
  interventions with indigenous clients?

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Project Need Sources of Bias in Assessment

• Normative data
• Cultural disparity between tester and testee
• The cultural context of behaviour (setting)
• Representativeness of test performance within
  cultural context

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What is currently happening in the field
Literature Review

• 1. The continued use of mainstream measures of
  mental health and mental health outcome (consumer
  and clinician rated)
• Mainstream assessment measures eg. HoNOS, LSP-16,
  K-10
• Issues of reliability and validity of tests
• Evidence of bias
• The difference versus deficit debate
• Face validity
• Predictive validity
• Criterion validity
• Construct validity

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Why not adapt and validate existing measures?

• Involves applying a non-indigenous framework
• Lack of support from Indigenous communities
• Outcome is determined without reference to
  cultural factors which affect mental health and
  outcome
• No acknowledgment of culture-bound disorders
• Restricted comparability with mainstream measures
  
• No acknowledgment of cultural issues which may be
  impacting on client presentation and mental
  health outcomes
• No assessment of the extent of cultural
  impairment experienced by that individual.

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The development of unique mental health outcome
measures

• Accounts for differences in the conceptualisation
  of mental ill health amongst Indigenous
  communities
• Development of culturally-valid outcome measures
• High levels of validity and reliability,
  especially criterion, face and cultural
• Has already occurred with great success in New
  Zealand with indigenous populations
• A consumer rated measure has already been
  developed for use with indigenous populations in
  Australia

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The development of the Westerman Aboriginal
Symptom Checklist for Youth (WASC-Y) as a
consumer rated measure

• Developed to account for differences in the
  conceptualisation of mental ill health amongst
  Indigenous communities
• Measure already culturally-validated for use in
  Indigenous populations
• 5 clear factors (accounting for between 40-70 of
  variance)
• High levels of validity and reliability,
  demonstrated through Factor Analytic studies and
  calculations of internal reliability (Cronbachs
  alpha levels of .85 - .90)
• Already gained high degree of acceptance in WA
  and the NT

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Why develop unique measures

• Ensures reliability and validity
• Cost does not represent a significant difference
• The development of unique measures is a concept
  that is clearly embraced within the Aboriginal
  and non-Aboriginal community
• It is good science! And ensures that case
  planning and interventions are valid.

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Ways Beyond Development of Measures How to
minimise bias in the assessment of Aboriginal
clients.

• 1) Improving the cultural competence of testers
• Development of cultural competence as minimum
  standards of practice for clinicians, including
• Cultural awareness and beliefs
• Cultural knowledge
• Flexibility
• 2) The use of cultural consultants
• 3) Including indigenous conceptualisations of
  mental health and mental health outcome
• (a) Culturally determined views of mental
  health disorders
• (b) Ensuring that (consumer-rated) measures
  have validity
• 4) Incorporating traditional methods of problem
  resolution into interventions through recognising
  the traditional hierarchy of problem resolution
  within interventions.

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Minimising bias

• 5. The development of Clinician Guidelines for
  the purpose of
• Accounting for all possible sources of cultural
  bias within the assessment process
• Identification of possible culture-bound
  syndromes within symptom presentation.
• 6. Establish the cultural validity of
  outcomes through a cultural validation process
• 7. Use of an acculturation measure
• 8. Acculturative stress index.

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A cultural validation process

• To increase the validity and reliability of
  outcome measures
• Identify the areas of cultural bias within
  outcome measures
• Improved mental health outcomes
• Increased service utilization through the
  recognition of traditional methods of resolving
  mental health problems.

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Purpose Of Cultural Validation

• To ascertain the following
•  Can the mental illness be best explained as a
  culture-bound syndrome (eg. Depression, psychosis
  or culture)
• Is the behaviour organic or reactive to being
  away from country, or being assessed outside of
  situational context.
•  

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Purpose Of Cultural Validation cont

• IS THERE A MATCH BETWEEN ALL ASSESSMENTS
  CONDUCTED?
• INTERPRETATION OF CULTURAL VALIDATION
• Assessment non-Aboriginal way Individual
  validation cultural validation ASSESSMENT IS
  CULTURALLY VALID
•  Assessment non-Aboriginal way DIFFERS from
  Individual or Community validation ASSESSMENT
  NOT CULTURALLY VALID

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Purpose Of Cultural Validation cont

• Range of culture-bound syndromes (Westerman,
  2000 Vicary, 2001)
• Psychosis
• Being sung by an aggrieved party
• Sorry time -
• pathological grief and hysteria
• self harm
• Longing for and being sick for country
• Rituals - obsessional and compulsive behaviours
• Payback - external attribution belief system

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Indigenous Psychological Services

• email tracyw_at_ips.iinet.net.au