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SCHOOL OF PUBLIC HEALTH & COMMUNITY MEDICINE THE UNIVERSITY OF NEW SOUTH WALES SYDNEY AUSTRALIA
THE POLITICAL THE POLITICAL ISIS THE THE CLINICALCLINICAL
Comfort zones, cultural safety and Indigenous ‘mental’ health
MURU MARRI INDIGENOUS HEALTH UNIT
In SummaryIn Summary
MH services fail blackfellas in multiple ways
Re-conceptualising MH as well-being is likely to enhance outcomes, but mandates organisational change
In SummaryIn Summary
International indigenous experience offers
clues, but there are crucial elements unique
to the Australian situation
Change involves a suite of personal and
political challenges, de-‘Othering’ and
culturally safe practice
Indigenous Health StatusIndigenous Health Status
Worst of any group in Australia Median age death (males) 51 yrs
- 26 yrs < non-Indigenous Life expectancy ↓ Maori, Aboriginal
Canadian, Native American Many conditions preventable
Mental Health StatusMental Health Status
NSW figures: self-reported ‘mental
distress’ almost 2 x non-Indig. rate Specific diagnoses: depression, anxiety, bi-
polar disorder, complex PTSD, borderline
personality disorder, A&OD misuse,
cannabis/amphetamine psychosis, but …
Focus on ‘Mental’ Health / IllnessFocus on ‘Mental’ Health / Illness
History of incorrect diagnosis History of medical complicity in eugenics
movement, ‘locked’ hospitals, child
removal and separatist political schemes Negative, ‘deficit’ approach – ignores
social, historical and cultural aspects,
including resilience
ThenThen
NowNow
I’m not ‘mental’I’m not ‘mental’
Narrow approach: no longer acceptable Stigma Lack of fit with Koori understandings Ignores on-going loss and contemporary
consequences of trans-generational trauma Ignores the crucial contribution of
exogenous, early psychic trauma
I’m not ‘mental’I’m not ‘mental’
Psychobiology / Body memory of trauma
– Bessel van der Kolk Psychoneurobiology / Developing brain &
trauma – Bruce Perry, Alan Schore Intergenerational Trauma – Yael Danieli Critical Psychology – Erika Apfelbaum Critiques of Bio-Psychiatry – Peter Breggin
Indigenous PerspectiveIndigenous Perspective
Blackfellas say fundamental connection between colonization and ‘mental distress’
Holistic approach: mental health inseparable from overall health Preferred term is social, spiritual and emotional well-being
Positive ApproachesPositive Approaches
Jettison ‘Deficit’ Model, i.e. that:
Inherited factors explain most Indigenous Australian mental distress
The rest is sheer bloody-mindedness: ‘blacks behaving badly’
Positive ApproachesPositive Approaches
Attend to the social determinants of health: the role of history, politics, geography, culture and socio-economic status
Incorporate recognition of culture and the contexts of people’s lives into treatment/prevention
Towards an integrated modelTowards an integrated model
CulturalSafety
Cultural Awareness
Cultural Competence
Indigenous / CALDB well-being Indigenous / CALDB well-being
Common aspects to working across Indigenous and CALDB populations?
Yes
Same thing?
No: unique aspects of Aboriginal and Torres Strait Islander situation
‘‘First Nations’ First Nations’ StatusStatus
Aboriginal and Torres Strait Islander Australians occupy a unique position as the original inhabitants of Australia
Sovereignty has never been ceded or attenuated by treaty
Indigenous Health StatusIndigenous Health Status
Effects of 200 years of colonization on health
Dispossession – land, language, culture, economic base → grief and loss
‘Stolen Generations’ Trans-Generational Trauma Multi-Generational Chronic Stress Racism, discrimination and ‘virtual’ apartheid
Colonization to healingColonization to healing
Clue from NZ MH competency framework ~ Specific reference to healing for Maori
Similar calls in Australia, but not mandatory - little recognition of:
~ Effects of colonization on health ~ Relationship of ATSI to land / spirituality ~ Sovereignty issue
Big pictureBig picture: treaty and health : treaty and health
Big pictureBig picture: culture and health: culture and health
Connection to culture, language, land
‘protective’ of well-being (Aust./NZ, Jane
McKendrick) Notion of ‘Cultural Resilience’ (US, Iris
HeavyRunner and Kathy Marshall)
Big pictureBig picture: culture and health: culture and health
Big pictureBig picture: Cultural Presence: Cultural Presence
Cultural Safety / Cultural Security affected by relative presence or relative absence of Indigenous culture in the life of the nation
Big pictureBig picture: Minoritisation: Minoritisation
Bruce Perry: psychologically fraught to leave the living culture of the reservation / whanau / Aboriginal community to become a ‘minority’ individual in a western cultural framework
Minoritisation = a reduction in regard
Big pictureBig picture: Minoritisation: Minoritisation
Does such ‘minoritisation’ multiply the
effects of marginalisation?
When you’re already culturally absent /
beyond the pale, does that make it even
easier to become diminished or infantilised
as a person?
Clinical picture: better praxisClinical picture: better praxis
Ngara“Listen, hear, think … (Eora, the Sydney language) to listen is simultaneously to reflect and become self-aware.”*
* Paul Carter
Clinical picture: better praxisClinical picture: better praxis
Resonance with Cultural Safety
Precept of health professional self-
reflection / examination of own
cultural system
De-Othering Indigenous AustraliaDe-Othering Indigenous Australia
Acceptance of alterity, small ‘o’ otherness
Cultural Imbrication / Cultural Interaction
Up-close-and-personal involvement
Everyday enmeshment, rather than policy fiat
Accepting small ‘o’ othernessAccepting small ‘o’ otherness
Extending our praxisExtending our praxis
To improve Indigenous social, spiritual and emotional well-being it’s time to:
Move beyond DSM IV Move beyond diagnose / treat Go further than the client / professional
dyad
Extending the modelExtending the model
CulturalSafety
Cultural Awareness
Cultural Competence
Cultural Imbrication
The political The political isis the clinical the clinical
Aboriginal and Torres Strait Islander emotional well-being a complex endeavour
Need for positive approaches, a taking account of social determinants and grappling with unfamiliar imperatives: cultural competence / cultural safety / cultural imbrication
But … all this impliesBut … all this implies
Personal challenge to existing comfort zone Professional challenge
# To models of professional distance and
non- disclosure
# Mandates organisational change
But … all this impliesBut … all this implies
Political Challenge
# Implications for training: systems/funding
# Implications for competency standards
# Implied need for increased practitioner
advocacy
‘‘Not For Service’ Rpt. Calls ForNot For Service’ Rpt. Calls For
Funding: increase MH to 12 per cent of total health care funding
Policy: monitoring extent of MH problems PLUS A&OD integration with the National MH Strategy
Leadership and governance: federal Minister PLUS true collaboration between all stakeholders
‘‘Not For Service’ Rpt. Calls ForNot For Service’ Rpt. Calls For
Legal and Human Rights: nationally consistent guidelines on the provision
of MH care Workforce: urgently address the declining
morale and chronic skills shortages in the MH workforce
Accountability: annual reporting mechanism on key indicators, including
10-year targets
The political The political isis the clinical the clinical
Re-emerging role for public intellectual
in conservative times Australian Govt. denial of contemporary
consequences of past practices leads to
inequitable, ineffective policy Time to re-conceive role of health
professional as public professional
The political The political isis the clinical the clinical
Governmental and organizational denial can be as unshakeable as alcoholic denial
Confrontation with evidence-base for fresh approaches to Indigenous well-being a necessary, but not sufficient condition
The political The political isis the clinical the clinical
Clinical duty of care mandates a ‘political’ set of activities to circumvent denial
Could be pursued through changes to the parameters, language and tone of the debate
Requires practitioner involvement in creation of a parallel discourse
The political The political isis the clinical the clinical
Time for Boldness Insist government policy founded-on contemporary effects of loss and TGT Insist initiatives be funded according to need, are sustainable Insist anything else violates professional duty of care