Indigenous Mental Health Service Delivery: Why do we need a Unique Service?

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Indigenous Mental Health Service Delivery Why do
we need a Unique Service?

• Dr Tracy Westerman
• Managing Director
• Indigenous Psychological Services
• Post Doctoral Research Fellow, Curtin University
  of Technology, WA

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Indigenous Psychological Services and RC
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SEWB Centre

• SEWB Centre for the Metropolitan, Great Southern
  and South West
• Training of workers
• Support for workers
• Ongoing workshops
• 3 new staff
• Service Manager (1)
• Project Officers (2)

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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
• Memmott et al (2000) suggest rates of 80 of
  incarcerated indigenous youth have been abused
• Death attributable to external causes (Hunter,
  1998)
• Data from Kids Helpline - 35 of calls regarding
  current abuse
• Alcohol and drug useage

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WHY?

• Misdiagnosis, overdiagnosis and underdiagnosis
• Cultural differences seen as deficits and
  indicators of mental illness / dysfunction
• Range of cultural triggers implicated in mental
  ill health (Westerman, 2000 Vicary, 2001)
• Differential cultural and clinical diagnosis
  (e.g. FAS)
• Auseinet data base cites lack of Indigenous
  specific intervention programs
• Systematic Evaluation of prevention programs is
  lacking
• Notions of cultural competence in service
  delivery

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Why?

• No focus on identifying specific Aboriginal risk
  factors in research or programs
• Programs are largely diversionary or reactive in
  nature
• Limited focus on reducing known risk factors in
  mainstream (I.e. racism) concomitant with
  indigenous programs
• Individual versus community treatments

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What has been done to address rates of mental ill
health?

• 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
• The evidence for community development approaches

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Problem 2 Inequities in research

• Quality versus quantity research
• Methodological problems with existing research
• use of a range of different measures with no
  established validity or reliability
• data collection techniques
• Prevalence of mental disorders range from 1.8,
  to as high as 51.2
• Compromises funding of intervention programs
• No evidence base regarding what works

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Problem 3 Appropriateness of existing services

• Access to services
• Levels of engagement
• Primary versus secondary / tertiary level
  services
• No information on the nature of the workforce
• Lack of clinical skills and cultural appropriate
  services indigenous clients
• Less than half of all non-indigenous
  practitioners feel competent with Aboriginal
  people
• Less than half of all indigenous practitioners
  feel clinically competent with Aboriginal clients
• The dual struggle

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Problem 3 Assessment and Diagnosis

• Adequacy of methods of assessment in use
• Major epidemiological studies and representation
  of Aboriginal people
• Is there a different aetiology?
• Mainstream factors at a higher rate, and/or a set
  of unique risk factors that account for the
  higher rates of mental ill health?
• Confusion regarding the definition and diagnosis
  of mental ill health

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Problem 4 Treatment of mental health

• Treatment efficacy unknown
• Medication rates
• Traditional Treatments - the absence of evidence
  argument
• Comorbidity - identification, diagnosis and
  prognosis
• Aboriginal people seek cultural reasons and
  cultural solutions prior to any other treatment
• External attribution belief system and problems

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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

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Solution 1 Ongoing quality research

• Ongoing quality research
• Determining Treatment Efficacy
• Traditional and westernised treatments
• Cultural resilience as a moderator of illness
• Understanding indigenous specific risk factors in
  mental health
• Impact of child-rearing practices
• Population versus individual level risk

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Solution 2 Increasing Workforce Skills

• A. Defining workforce on the basis of cultural
  competence as minimum standards
• 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)

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Increasing Access to Services

• Training of Indigenous and Non-Indigenous people
  in tandem
• Improving Efficacy of Engagement
• Empirical models of intervention lacking -
  articulate what is different
• N 189 youth, 98 engagement rates

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Solution 3 Developing Culturally Valid
Assessment Protocols

• The Westerman Aboriginal Symptom Checklist -
  Youth WASC-Y - for Aboriginal youth aged 13-17.
  
• WASC-A
• IWABI

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Results of culturally validated mental health
screening tool

• Range of mental health prevalence data
• Information on comorbidity
• Able to identify for early stage of risk
• Able to evaluate efficacy of counselling and
  intervention services
• A range of strategies aimed at minimising impact
  of cultural differences between client and
  clinician
• Impairment within a cultural context
• Assessing the predominant belief system of client
• Assessing for cultural triggers to disorder
• Assessing for culture-specific disorders

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Solution 4 Increasing Treatment Efficacy

• A. Development of information regarding the
  existence of CB disorders
• The absence of evidence argument
• 1. Being Sung 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

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Increasing Treatment Efficacy

• B. Model for the resolution of C-B disorders
• 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

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Therapeutic interventions

• 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

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Solution 5 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 youth through
  Australia (75 Aboriginal).
• Developed from within the Aboriginal culture
• Incorporates indigenous worldview (e.g. conflict
  resolution and payback hierarchies of power in
  problem resolution)
• 17 different packages

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How Indigenous specific information can be of
benefit?

• Statewide Suicide Prevention Forums
• Features
• Demand for forums from the community
• Developed specifically for Aboriginal people
• Content specific to context
• Community Development approach - youth, community
  and service providers (N425)
• Introductory, Follow-Up and Counselling Support
• High risk regions and potential for risk
• Outcome driven evaluations

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Recruitment and Retention

• Recruitment culturally appropriate tests and
  practices
• Retention training
• Managing mood
• Managing my Family and Community Now that I am a
  Wage Earner
• Communication Skills
• Managing Conflict / Assertive Communication
• Problem Solving
• Working with Non-Indigenous People
• Working as a Team / Creating a Team
• Career Planning
• Leadership Skills

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Models of Best Practice what is stopping us?

• Empirical validation
• Cultural validation
• Replication of models for use with other issues
• Transferability across different groups
• Longitudinal data
• Sustainability
• Access to service providers to deliver culturally
  and clinically valid programs
• Studies show success of programs depend on
  community self-management and ownership

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How to Contact Us

• Indigenous Psychological Services
• Suite 3, 20 Twickenham Street, Burswood, Western
  Australia, Australia
• 08 9362 2036
• ips_at_ips.iinet.net.au
• www.indigenouspsychservices.com.au