Implications for Engagement in Mental Health Services
In Durie’s (1997) term, Western paradigms of ‘mental health’ suffer from ‘conceptual isolation’: it is the limited conceptual base that constrains the development of services, assessments, interventions, and even practitioner training that are relevant and effective for Indigenous Australians (Durie 1997; Thorpe and McKendrick 1998). Existing psychiatric diagnoses often provide neither an acceptable fit with Indigenous explanatory models of illness (Gabb and McDermott 2008), nor facilitate an appropriate service response (Swan and Raphael 1995; Brown et al. 2012; McKendrick and Thorpe 1994). Westerman has described usual, ‘mainstream’ practice as offering a:
[l]imited base of specialised therapeutic interventions steeped in conceptual, evidence-based treatment models. (Westerman 2004, p. 4)
What is required, rather, is an expanded praxis—an ‘Indigenised’ praxis— based on a conceptual framework that is holistic in both structure and implementation.
Currently, engagement in services is compromised by bio-medically premised configurations that inadequately address Indigenous preferred responses. Complex presentations are common, with court and justice issues, family violence issues, problematic alcohol and other substance use, child protection questions, and housing insecurity inseparably relevant to any mental distress intervention (Krieg 2006; Cripps 2010; Tilbury 2009).
Two logical consequences of the argument that we have made, thus far, in this chapter are that control and self-determination will be necessary elements of any effective and sustainable solution, as will be the acknowledgement and accommodation of Indigenous perspectives. Endorsing the importance of control and self-regulation will necessarily entail incorporating stakeholder involvement in the design and implementation of mental health services. This point will be returned to later in the chapter.
Control is also fundamental to the social determinants of health with Marmot (2006), reminding us that:
What is important is not so much what you have but what you can do with what you have. (p. 565)
While the important link between social determinants and physical health is well established, it is also being increasingly recognised that social determinants are just as important to mental health (CSDH 2008).
In order to address the engagement of Indigenous Australians with appropriate services, it is essential, also, to be clear about what is meant by ‘engagement’. One approach is to consider mental health services as resources that people can use to make their lives more as they would like them to be, not as programmes or plans that are applied to individuals to shape or mould them in particular ways. There is a connection here between enhancement of the ‘control factor’, client-centred service configuration, and facilitating resilience—all in the name of better mental distress outcomes. The work of Michael Ungar and colleagues, across a number of international settings, re-positions resilience as something greater than individual ‘defiance-of-the-odds’. In the context of exposure to significant adversity, resilience can instead be seen as:
both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being, and their capacity individually and collectively to negotiate for these resources to be provided in culturally meaningful ways. (Ungar 2014, n.p.)
Service engagement, from such a perspective, then, begins from a premise of Indigenous Australians being active agents rather than passive recipients of services. It also implies that when services are not being engaged by Indigenous Australians, we should address the service being offered, rather than the person who is currently not taking up the offer. It is important, therefore, to consider engagement from a perspective informed by the needs, desires, and lived reality of the person accessing the service, rather than from the perspectives of the service providers.
Grieves (2009) argues that something much more radical is required than making premises ‘Aboriginal-friendly’ and providing cultural awareness training for practitioners. A service, for example, that prominently displayed Indigenous artwork and ensured all employees had some cultural awareness training yet still diagnosed and treated mental health problems according to Western standards would be missing the point. Berry and Crowe (2009) endorse this view by suggesting that difficulties with engaging Indigenous clients relate to both limited access to services and a lack of cultural respectfulness of the services. The lack of culturally derived empirical models of practice that are applicable, particularly to Indigenous youth, is cited as another reason for poor engagement with services (Westerman 2010).
In one study, participants perceived that Western-style therapy was culturally inappropriate or irrelevant (Vicary and Bishop 2005). In this study, fear of the Western mental health system was reported by Indigenous Australians because of the stigma associated with being labelled mentally ill, as well as the possible imposition of certain treatments, such as involuntary hospitalisations and medication. Vicary and Bishop (2005) point to the implications for Indigenous engagement with mental health services in noting that participants in their study:
actively withheld mentally ill family members from Western services because
they were concerned about the possible outcomes. (p. 12)
It is not that fears of stigma and compulsory treatment only bedevil Indigenous Australians: what is noteworthy with respect to Indigenous engagement, rather, is that such fears are compounded by not only historical factors— sometimes generic to the project of colonisation itself, and sometimes specific to the Australian context—but also the impact of a range of contemporary determinants of Indigenous mental health and well-being. Relevant historical factors would include: the past existence of segregated hospital wards; a body of anecdotal (though substantial) evidence of past, forced sterilisations; and the body blow to trust of widespread forcible child removal over many decades— where doctors, hospitals and other health system actors were viewed as active agents in the processes contributing to the ‘stolen generations’. Contemporary barriers to resolving the twin impediments of reluctance to engage and early dis-engagement—including even self-discharge, or ‘taking own leave’, in life- threatening situations, before the completion of the interventions or treat- ment—revolve around perceptions of a lack of cultural safety in the health service on offer (Einsiedel et al. 2013). Given recent research suggesting that racism in health settings may have a more negative impact than racism in other settings (research that echoes long-standing Indigenous Australian narratives of how health services can make them feel ‘sick’), adding the likelihood of encountering racism to concerns about inappropriate modes of health-care delivery may lead to greater risk of dis-engagement (Kelaher et al. 2014).
Any discussion about the importance of perspective, however, would be incomplete without including reference to the unequal power relationship between client and professional—and the way in which this imbalance can inform, or hamper, service delivery. To provide services that Indigenous Australians would want to engage with, it is crucial for service providers to be aware of their own assumptions, attitudes, beliefs, and values. This requires not only fostering health professionals' reflection on their own culture in relation to therapeutic interactions but, also, the re-positioning of such reflective practice as the default setting for effective cross-cultural work, that is, as core clinical, health promotional, and organisational business. One exemplar approach which encapsulates the need for the mitigation of power differentials—for the development and embedding of self-reflective practice, and for treating clients ‘regard-ful’, rather than regardless, of difference—is the earlier mentioned approach of cultural safety.
The same precepts of recognising and reducing power differentials, self- reflexivity, and conscious avoidance of a conflation of equity and sameness of treatment (often expressed as ‘I just treat everyone the same’) are central to a number of other approaches that are of similar pertinence to facilitating better Indigenous Australian engagement in mental health services. These include: cultural humility (Tervalon and Murray-Garcia 1998); the more nuanced and flexible models of cultural competence offered by Weaver (1999) (a model from a Native American perspective) and Goode and colleagues at the (US) National Center for Cultural Competence (Goode 2014); and the Australian-developed Integrated Model of Gabb and McDermott (2008). These approaches inform our comprehension of the minimum good practice requirements for effective cross-cultural service provision, yet their implementation holds major ramifications for individual practitioner training, organisational quality assurance, and overall service configuration.
At a pragmatic level, effective solutions will often be locally developed, and must be adequately staffed with appropriate funding models (Carey 2013a). Evaluation should be an ongoing and an inherent part of any programme with local knowledge and expertise being integral to the service (Carey 2013a). Issues of recruitment will be nuanced, so that it may be necessary to reconsider conventional employment position descriptions in order to employ the most appropriate staff. Early and ongoing community consultation will be an important facet of the continuity of the programme in order to ensure that the service being provided remains relevant to the needs of the community. Even the structure of interventions should be considered to avoid conflict with Indigenous communities’ concepts of time, relationships and obligations, and the ‘rhythm’ of community life (Robinson and Tyler 2008). These may include not only culturally significant seasonal ceremonies but, also, the need to halt business as usual, upon a community death—sometimes for extended periods—for the conduct of ‘sorry business’.