Western psychotherapeutic practice: Engaging Aboriginal people in culturally appropriate and respectful ways

Western psychotherapeutic practice: Engaging Aboriginal people inculturally appropriate and respectful ways

DAVID A. VICARY, & BRIAN J. BISHOP

School of Psychology, Curtin University of Technology, Perth, Western Australia, Australia

AbstractUntil recently the majority of psychologists in Australia have been confronted by the lack of information relating to culturallyappropriate methods of engagement and therapy with Aboriginal clients. Findings from a qualitative study undertaken inWestern Australia indicated that Aboriginal conceptualisations of mental health appear more holistic and contain elementsthat are both cultural and spiritual. The extent of these differences in conceptualisations from Western psychiatry andpsychology are so vast that the mental health interventions need to be reconsidered. Extending from an Aboriginal mentalhealth model are traditional treatments that endeavour to address the cultural and spiritual components of the mental illness.Findings from the study indicated that these treatments appeared to be hierarchically organised, depending on cause, severity,type of practitioner required and treatment. The findings also indicated that Aboriginal people generally seek traditionalinterpretations and treatment of an illness and exhaust these avenues prior to contact with the Western mental health system.The research also delineated Aboriginal beliefs about Western psychotherapy, including conceptions about Western therapy.The authors propose an engagement model, including formative preparation, for non-Aboriginal practitioners intending towork with the Aboriginal community.

The mental health of Aboriginal people has been

largely neglected in Australia.1 There are few studies

available to the mental health professional providing

a detailed and practical insight into the Aboriginal

worldview; in particular the beliefs held that relate to

psychotherapy, mental health and non-Aboriginal

counsellors/therapists. Despite the lack of research

information, a number of mental health profes-

sionals working with Aboriginal people have de-

scribed some of the aspects of their work in articles

and conferences (Cawte, 1984; Dudgeon, Grogan,

Collard, & Pickett, 1993; Dudgeon & Williams,

2000; Hunter, 1993; Vicary & Andrews, 2000,

2001). The majority of this information has focused

on topics such as cultural sensitivity (Casey, 2000;

Crawford, 1989, 2000; Dudgeon, 2000a; Hunter,

1993; Slattery, 1987), strategies that enhance the

cultural appropriateness of therapeutic interventions

(Sykes, 1978) and belief systems held by a particular

group of Aboriginal people (Cawte, 1984; Roe,

2000).

Numerous authors have argued that mainstream

mental health services are not meeting the needs of

Indigenous clients (Hunter, 1991; McKendrick et

al., 1990; Nurcombe, 1970). Swan and Raphael

(1995), as part of their National consultancy report

on Aboriginal and Torres Strait Islander mental

health, concluded that the disadvantages that char-

acterise Aboriginal people’s position in Australia also

increase their vulnerability to the development of

some types of mental illness. Mainstream mental

health services often fail to meet Aboriginal mental

health requirements. Additionally, Swan and Ra-

phael noted the impact that grief, trauma, suicide,

self-harm and substance abuse has on the collective

psyche of the Aboriginal population. They advocated

specialist mental health services for Aboriginal men,

women, and children.

The National Health Priority Areas (1998) report

found that mental health has only recently been

identified as a priority for Aboriginal people. It is

acknowledged that the difficulty that many Abori-

ginal people have in talking to mental health

professionals is due to stigma, cultural misunder-

standing, involuntary confinement, and the failure of

past mental health approaches. It is difficult to grasp

Correspondence: B. Bishop, School of Psychology, Curtin University, PO Box U1987, Perth, WA 6845, Australia. Tel.: +61 8 9266 7181. Fax: +61 8 9266

2464. E-mail: [email protected]

Australian Psychologist, March 2005; 40(1): 8 – 19

ISSN 0005-0067 print/ISSN 1742-9544 online # The Australian Psychological Society Ltd

Published by Taylor & Francis Ltd

DOI: 10.1080/00050060512331317210

the extent of the impact of loss, separation and

traumatic experiences upon the Aboriginal popula-

tion because there is no national database available

to allow such comparisons. Locally collected statis-

tics illustrate that such factors are related to

psychosocial morbidity, particularly depression. Si-

milarly, there are no national data available that

reflect the nature of trauma, grief and loss and how

they impact upon the physical and mental health of

Aboriginal people.

In recent times there has been a movement in

Australia towards self-determination in mental

health care provision (Swan & Raphael, 1995) and

culturally appropriate counselling and service provi-

sion for Aboriginal people (Dudgeon et al., 1993).

However, little has been done to increase the skills

and knowledge of non-Aboriginal (NA) clinicians,

the majority of whom may never have come into

contact with Aboriginal clients (Slattery, 1987;

Vicary & Andrews, 2000). Those therapists who do

regularly work with Aboriginal people, families and

communities have developed their knowledge base

from personal experience or anecdotal information.

Such information is often difficult for other NA

professionals to access and is sometimes not

practical when it is obtained.

However, some professionals working with Abori-

ginal people have described aspects of their work in

articles and conferences (Brown & Larner, 1992;

Cawte, 1984; Dudgeon et al., 1993; Freedman &

Stark, 1993; Hunter, 1993). Most of this information

has focused on topics such as cultural sensitivity

(Slattery, 1987), strategies that enhance cultural

appropriateness of interventions (Freedman & Stark,

1993; Sykes, 1978), and belief systems held by a

particular group of Aboriginal people (Cawte, 1984).

Both Aboriginal and NA authors have described

the manner in which the Western mental health

system has disadvantaged Aboriginal people (Brown

& Larner, 1992; Freedman & Stark, 1993; Rosen,

1994) and documented the need for self-determina-

tion in the provision of mental health services

(Dudgeon et al., 1993; Sambono, 1993). Others

have suggested blending Aboriginal and NA models

of mental health and intervention to improve the

quality and cultural sensitivity of mental health

services provided to Aboriginal people (e.g., Dud-

geon et al., 1993).

Writers from other countries (e.g., Waldegrave,

1985) have argued that attempting to employ a white

mental health system, which is essentially mono-

cultural, with indigenous people, is a form of racism.

Others have viewed the Western use of psychother-

apy with indigenous people as a form of colonisation

(Tapping, 1993).

Despite the majority of the existing journal articles

appearing to focus on the areas of methodology

(Slattery, 1987, Vicary, 2003; Vicary & Andrews,

2000), belief systems (Roe, 2000; Sambono, 1993;

Sykes, 1978) and process (Hunter, 1993), little

information exists that examines deficits in knowl-

edge about Aboriginal attitudes and beliefs per-

taining to: (a) mental health; (b) Western psy-

chotherapy; and (c) non-Aboriginal counsellors/

therapists. Internationally there is a substantial body

of cross-cultural literature that examines the role of

Western-oriented mental health interventions and

the role of the non-indigenous practitioner in work-

ing cross-culturally with indigenous peoples (Sue &

Sue, 1999). However, until more research is under-

taken in Australia to examine these areas, the

relevance of international indigenous research will

remain unclear. The study reported here aimed to

address some of these gaps in knowledge and

provide insight into improved psychological inter-

vention by NA practitioners.

Method

Prior to conducting the study, approximately 18

months was spent canvasing the Aboriginal com-

munity, both in the Perth metropolitan and

Kimberley regions, as to the relevance and poten-

tial use of the study. Feedback from these

consultations was instrumental in the design of

the methodology and included the development of

an Aboriginal steering group, use of cultural

consultants and cultural validation processes. This

group consisted of 10 people, five from each region

and was gender balanced (three men and two

women in the north, and two men and three

women in Perth). A critical part of the research

centred on the steering group, who provided advice

and guidance on all aspects of the study, as well as

vouching for the researchers. This group was

formed by a process suggested by Aboriginal people

consulted in the scoping phase. An Elder who held

a senior position in government was approached

and they agreed to be the chair of the steering

committee. Five other people were recruited

because of their experience and knowledge of the

communities. This phase was very significant for

the implementation of the research because it

involved the Aboriginal community in a way that

was acceptable to them. It also allowed for cultural

validation of the methods and outcomes. The

implementation of the Aboriginal community-de-

rived methodology generated a significant degree of

interest and resulted in Aboriginal people from

across the state of Western Australia asking to be

included in the study.

The importance of the steering committee in

recruiting participants can be seen in the following

quotes:

Western psychological practice and Aboriginal people 9

I normally don’t yarn to gudyas [non-Aboriginal

people] about mental health concerns but I had a

yarn with [a Steering Committee member] and

she convinced me about the importance of what

you are doing. [female participant, 42 years,

Kimberley]

I wanted to come and check you out for myself. I

have heard all about you from this person and that

[Steering Committee member], but I was still not

sure. Now that I have met and yarned with you I

can see what he [Committee member] was getting

at. If he hadn’t got in my ear first I don’t know if I

would have come and had a yarn with you. [male

participant, 51 years, metropolitan Perth]

The qualitative study was conducted (2000 – 2002)

both in the Kimberley and metropolitan Perth

regions of Western Australia. In total 70 informants,

35 from each geographical region were interviewed.

The Steering Committee was involved in selection of

the interviewees. The respondents interviewed as

part of the study resided in either the Kimberley

region or in the metropolitan Perth region of

Western Australia. Of the Kimberley cohort, 11

subjects lived on remote Aboriginal communities or

out-stations; and the remainder lived in the towns of

Kununurra, Halls Creek, Broome, Fitzroy Crossing,

Wyndham, and Derby. Participants from the me-

tropolitan region were distributed throughout the

suburbs of Perth. Age ranged from 19 to 68 years.

There were 11 male participants in the Kimberley

sample and 24 female participants, while the Perth

sample involved 19 women and 16 men.

An interview schedule was constructed after

considerable consultation with the Aboriginal steer-

ing committee. Nine questions were finally arrived

at. The following are three examples of the ques-

tions.

1. If an NA counsellor was to work with an

Aboriginal family for the first time, and this

person had no experience of working with

Aboriginal people, what steps should he/she

take to make sure that their work was

culturally sensitive and appropriate?

2. If you had a mental health problem and

wanted to talk with someone but only non-

Aboriginal therapists/counsellors were avail-

able describe the person you would select?

3. Non-Aboriginal people often talk to counsel-

lors, psychiatrists or psychologists for assis-

tance with mental health problems. Do mental

health counsellors traditionally exist within the

Aboriginal community?

4. If so what types of problems might they help

with?

5. What skills and knowledge might they have?

The interviews were conducted by the researchers

with a cultural consultant, who helped in culturally

validating the interpretation of the data. The inter-

views were transcribed and the text theme analysed

using NUD.IST (Richards, 1998).

Four focus groups were conducted so that the

original informants could culturally validate the data

and subsequent interpretations. These groups were

held across both geographic regions (two each in the

Kimberly and in Perth). The focus group respon-

dents were derived from 20 study participants (10

from the Kimberley and 10 from Perth) who

indicated to the researcher that they were interested

in reviewing the findings in more detail and in

providing detailed feedback and recommendations

based on the results. All of the research process was

monitored and reviewed by an Aboriginal steering

group and by cultural consultants. Both groups

ensured that practice and procedures implemented

by the NA researcher were culturally appropriate,

sensitive and relevant. The findings of the study were

then sent to all of the study participants for their

information and advice prior to publication.

Findings and discussion

Analysis of the data revealed four metathemes that

transcended the majority of the study results. These

metathemes included: (a) the importance of culture;

(b) conceptualisations of mental health; (c) the

importance of Aboriginal mental health treatment

methodologies, and (d) the appropriateness of

Western psychotherapy when applied to the Indi-

genous population. The four metathemes were

consistent for both study groups and provided a

context for many of the responses and their

subsequent interpretations. For example, it is im-

possible to consider the results without taking into

account the crucial role that culture plays in

determining many of the responses made by study

participants (Collard, 2000; Sue & Sue, 1999).

The issue of the consistency between the data for

the two samples needs to be addressed. While

Indigenous psychologists (and others) have stressed

the need to be aware of the heterogeneity of

Australian Indigenous peoples (Dudgeon, Garvey,

& Pickett, 2000a), the results reflect a great deal of

overlap in the cultural understandings and treatment

of mental health issues. This is a complex issue

because it implies that there are considerable

similarities in fundamental social patterning, but

this issue is beyond the scope of this article. The

generalisability of the results and the suggested

model of intervention is questionable and care needs

to be taken. We would assert that the model is likely

10 D. A. Vicary & B. J. Bishop

to be generalisable, but this remains an empirical

question.

The influences of culture extended to include

Aboriginal conceptualisations of mental health,

traditional treatment methodologies and attitudes

to Western psychology and practitioners. These

findings suggest that culture is a powerful determi-

nant of many facets of Aboriginal people’s percep-

tions of mental health. For example, Aboriginal

interpretations of mental illness often do not have

the Western conceptualisation of a direct causal link

(e.g., smoking can cause cancer), rather the illness

may be related to a spiritual or law transgression.

Understanding culture’s influence in the domain of

Aboriginal mental health will ultimately assist the

practitioner in providing culturally sensitive and

relevant interventions (Kleinman, 1980; Sue, Ivey,

& Pedersen, 1996; Sue & Sue, 1999).

The findings further suggested that traditional

treatment for mental health problems are widely

used in the Aboriginal community. This is consistent

with the view of Dudgeon (2000b) who asserts that

‘‘there can be no doubt that the role of traditional

healers in relation to social and emotional well-being

of Aboriginal Australians has been and continues to

be an important one’’ (p. 103). Many participants

stated that they would seek traditional treatments

rather than those offered by NA services. Further,

they would access Western services only when all

traditional avenues had been exhausted and there

was no other treatment option available.

Participants reported that they believed Western

psychotherapy lacked validity when used with

Aboriginal clientele. Generally, they perceived Wes-

tern style therapy as culturally inappropriate or

irrelevant. Considerable modifications to practice

and processes must take place to ensure cultural

sensitivity. Once they can work in a culturally

appropriate way, NA practitioners might be in a

better position to make meaningful contributions

(Dudgeon et al, 1993; Garvey, 1994; Sue & Sue,

1999).

Aboriginal mental health and illness

The current study supports earlier findings (Swan &

Raphael, 1995) that indicate that Aboriginal con-

ceptualisations of mental health appear to be more

holistic and contain elements that are both cultural

and spiritual. This metatheme, along with the

metatheme of culture, have a profound influence

on the study findings because together they provide

the foundation for Aboriginal mental health beliefs,

attitudes and practices.

When asked to define mental health many of the

study participants stated that they found it an

extremely difficult concept to articulate. The reason

most commonly cited was that Aboriginal concep-

tualisations of mental health and illness do not have

the mind – body dichotomy often used in Western

mental health beliefs. Instead, Aboriginal beliefs are

more holistic and are better conceptualised as

wellness. Being well from an Aboriginal worldview

incorporates the physical and mental elements as

well as the cultural and spiritual aspects of health.

Other factors impacting on a person’s wellness

include employment status, substance abuse, family

violence, dispossession, effects of the Stolen Gen-

eration, cultural identity, and housing and financial

problems. An Elder from the Kimberley reported

that being well was like a large pizza with each slice

representing an element of someone’s life. If a slice is

removed the pizza is no longer whole. When

elements of a person’s wellness are compromised

they may be predisposed to physical or mental

problems.

Although many study respondents expressed

difficulty in defining mental health, they were able

to identify factors seen in the Western conceptualisa-

tions as contributory to mental illness. Despite this,

most participants maintained that if an Aboriginal

person became unwell, a direct causal relationship

with a disease entity or biological phenomenon might

not be perceived as the reason for the illness. Instead,

Aboriginal people looked to spiritual factors, and

other factors such as those identified in the pizza

model, that may impact on the person’s wellbeing.

For example, participants identified that a mental

illness might be perceived as payback for a previous

transgression that may also be related to other family

members’ transgressions. The Aboriginal perception

of the cause of illness might be due to being: (a)

‘‘sung’’ by an aggrieved party; (b) married ‘‘wrong

way’’; (c) ‘‘caught out’’ at law time; (d) Law business

and (e) other cultural factors. The responses from

study participants from both the Kimberley and the

metropolitan area indicated that a cultural or

spiritual reason for mental illness would most likely

be considered before other explanations.

Connection to country was another important

determinant of mental health identified by the study

participants. The results suggested that individuals

who are away from their country (place of birth/

Dreaming) for extended periods of time might

experience episodes of depression due to their

weakened spiritual link with country and commu-

nity. Participants asserted that it was important for

Aboriginal people to return home on a regular basis

so that they could remain connected to their country.

For example, one participant stated:

Yeah, there’s that longing and that yearning to go

back to country. Like my mother’s a Torres Strait

Islander and I haven’t been over to Thursday


Island and if I don’t get there before I die to me it

will be, it’ll just be a state a depression for me

because I haven’t seen my mother’s country. And

you know it’s sort of going back to your begin-

nings, where you come from and so then that sort

of like that fills that jigsaw in the life of who you

really are. It’s your make-up, it’s your beliefs. It’s a

personal thing like I don’t know my mother’s

country, I don’t know my mother’s people so I

need to fulfil that as part of my identity. If I don’t

know that how can I tell my children. Yeah. So

that’s what I have analysed as a cry for country for

me yeah. It’s just filling that missing piece in your

life, it’s making your circle complete. It’s like, how

do you put it. Like sometimes when you get really

stressed and you feel as if you are running around

in circles, whereas if you had a home you knew

your place and country, where you come from,

there’s some comfort in knowing that one day

you’re going to go back there. It’s like I always I

say to my kids, this is not my home it’s not my

country, when I die you have to bury me back

home. So you have to transport me back there to

my country. [Female participant, 46 years, me-

tropolitan Perth]

They reported knowing when it was time to go

home due to alterations to their mood state or a

longing or compulsion to return home. Not being

able to go home to ameliorate these feelings could

lead to a deterioration of an individual’s mental state.

The NA therapist should take into account the issue

of country and the associated beliefs and practices if

they are to work effectively with Aboriginal clientele

(Dudgeon, Garvey, & Pickett, 2000b).

Further, study participants acknowledged that

Aboriginal people were often unaware of mental

health issues due to a lack of culturally appropriate

mental health promotion and the community’s

reticence to discuss the issue, as well as due to the

concept being culturally alien. Typically, and per-

haps similar to NA society, a mental health problem

needs to become visible to the family or community

before action is taken. Mood states are often

perceived as being characterlogical traits of the

individual and not transitory states. A typical

response about a person suffering depression or

anxiety was ‘‘Oh that’s just the way he/she is.’’ This

attitude has obvious implications for suicide preven-

tion (Vicary & Ford, 2001).

The obvious differences between Aboriginal and

Western conceptualisations of mental health have

the potential to create major problems for the NA

worker unaware of these fundamental differences.

The study findings are consistent with both Aus-

tralian and international literature examining Indi-

genous mental health (e.g., Casey, 2000; Collard,

2000; Crawford, 1989, 2000; Sue & Sue, 1999;

Swan & Raphael, 1995; Tapping, 1993; Waldegrave,

1985). Aboriginal people believe that divine spirit is

embodied in all things (Cowen, 1989). The Dream-

ing can be viewed as how Aboriginal people trace the

birth of the world and their place in it. The

connectedness between living things and land is

not unique to Aboriginal culture and such under-

standings can be found in many indigenous cultures

throughout the world (Tapping, 1993).

According to study participants, the major differ-

ences between Western and Aboriginal conceptuali-

sations of mental health related to the spiritual beliefs

inherent in Aboriginal health. They believed that the

spiritual world had an active influence on their

mental health status. Many Aboriginal people were

fearful of the Western mental health system because

they felt that there was a stigma attached to being

labelled mentally ill, and were concerned about

possible treatment outcomes (e.g., involuntary hos-

pitalisation, medication). Participants stated that

they actively withheld mentally ill family members

from Western services because they were concerned

about the possible outcomes. The family managed

the ill individual by sharing their burden and

accessing traditional or culturally appropriate ser-

vices. According to the respondents, Aboriginal

people had more tolerance for community members

who were mentally ill compared to NA people,

because they cared for their loved ones at home,

included them in daily activities, tried to minimise

the stigma and sought more holistic treatments. In

contrast, the participants’ perception of NA manage-

ment of the mentally ill included the family

immediately contacting the mental health system

for medication or treatment and, if the situation were

difficult, for hospitalisation.

Further exploration of Aboriginal conceptualisa-

tions of mental health addressed possible gender

differences in the development of mental health

problems. Respondents were of the view that

Aboriginal men were more likely to be predisposed

to a mental illness because their traditional role as a

provider had been weakened. Many men were

struggling with issues such as unemployment,

violence, social and geographic dislocation, and

substance abuse, and were not able to find work to

fulfil their role as family provider. This situation left

many men with low self-esteem, depression and

unable to see practical alternatives. Other research

(Bhatia, Titulaer, & Trickett, 1997) also supports the

belief that the destruction of the traditional male role

has resulted in Aboriginal men having the worst

health, including mental health, of any group in

Australia. Aboriginal men do not acknowledge

mental health issues, nor do they seek treatment to

resolve mental illness when it becomes apparent


(Akbar, Dudgeon, Gilchrist, & Pitt, 2000). Huggins

(1991) argues that Aboriginal men have felt the loss

of their culture more keenly than women because

they no longer control their society, politically or

spiritually. This has resulted in an identity crisis

accompanied with depression, violence and hope-

lessness.

The respondents also indicated that with the

traditional male role weakened, many women

assumed the role of family provider as well as their

traditional role as carer, thus further disenfranchising

the men. Women often obtained work more easily

than men because often they were better educated

and had skills that could be applied in many business

settings (Torres, 2000). Aboriginal women may be

protected against such illness because they have

assumed both of the major family roles, that of carer

and provider. Interestingly, participants commented

that Aboriginal women could not afford to become

ill because maintenance of the family structure

depended upon her fulfilling both of the key family

functions.

Traditional mental health treatments

Study participants maintained that when an Abori-

ginal person seeks traditional mental health services,

the treatments provided are hierarchically organised

depending on the perceived cause, severity, type of

practitioner required, country, gender and age (e.g.,

has the individual been through the Law process).

The first level of treatment provided to an individual

with mental illness comes from the immediate

family. This treatment may consist of support,

advocacy, yarning, practical advice and guidance. If

the problem continues to be an issue, members of

the extended family might be called in to assist. This

may result in the individual being sent to a relative

who has special skills or knowledge that may help

resolve the problem.

If the family does not have the capacity to provide

a solution, the community and the Elders may be

asked to assist. Participants related examples of

communities (and large extended families) develop-

ing support systems for mentally ill individuals so

they could remain on country rather than be

hospitalised. Depending on the nature of the

problem, the community Elders might suggest that

the person return to his/her country so they might

make a spiritual reconnection with the land. This is

particularly the case when the ill individual has been

away from their land for an extended period of time.

Family and community members may travel with the

individual back to country to act as supports and elicit

support from other community members.

If the problem is perceived as being spiritual or

cultural in nature, the patient may be referred to the

healer for specialist assistance. In terms of referrals,

it is important to consider that Aboriginal mental

health specialists are contacted through a third

person with the client’s knowledge, as is sometimes

similar to the some referrals to Western practi-

tioners. The practical application of culture means

that often a third person (usually a family member)

will contact the NA practitioner to let them know of

their concerns and request that the individual be

visited for a yarn. Generally each family has a healer

they can contact, but sometimes they may require

extra special intervention and a healer of renown will

be contacted.

Interestingly, the traditional treatment system for

mental health problems offers Aboriginal people a

viable alternative to Western services. Traditional

counsellors address many of the same issues as

Western systems; but they do so in a way that is not

perceived as a threat by the client. In contrast, many

Western therapies encourage the clients to self-

explore and find the answer for themselves. Accord-

ing to study participants this frustrates many

Aboriginal clients.

Culturally appropriate mental health intervention

Findings from this study suggest that Aboriginal

people would rather use traditional or Aboriginal-

specific services rather than Western mental health

services. However, there is also a recognition that at

times accessing Western mental health services may

be required for confidentiality purposes or because

there is a lack of traditional or same-culture services

(Casey, 2000; Dudgeon, 2000b; Dudgeon et al.,

1993). In time more mental health services may

become available to meet with the cultural require-

ments of Aboriginal people. Until this occurs it is

likely that services will be provided from a Western

framework by NA therapists. So that this form of

service provision is not viewed as a vehicle of

colonisation and oppression by Aboriginal clientele,

NA therapists should make themselves aware of

traditional practices and processes for the treatment

of mental health difficulties. Understanding a

different culture completely is not possible for those

outside the culture, and consequently provisions

must be made to ensure that NA therapists under-

take their work with Aboriginal people in a culturally

sensitive manner. This will require a shift in the

practice from Western models to more holistic,

culturally appropriate models of intervention. The

following model is proposed to facilitate both the

preparation of the NA practitioner and increase the

likelihood of successful engagement.

There is an issue of resourcing the proposed

methodology of engagement because it is involved

and time-consuming. The crux of the argument for


advocating this model is that current practices are

ineffective and resources are not being effectively

utilised. For example, there is anecdotal evidence that

some attempts to implement the Gordon strategies in

the Kimberleys are being hampered in some areas

because of the lack of housing to allow workers to be

embedded in communities, an essential part of the

strategy. Efficacy and effectiveness are concepts that

need to be addressed and we argue that efficacy

cannot be achieved without the latter.

Model for engagement

Formative preparation. Building strong relationships

with the Aboriginal community is really a central

theme of the engagement phase (Crawford, Dud-

geon, Garvey, & Pickett, 2000). Without a solid

relationship with the community the NA practitioner

may experience substantial difficulty in working with

local Aboriginal clientele. Informants from this study

suggested that once preconditions of the relationship

engagement phase (REP) were met, the NA practi-

tioner could begin working with Aboriginal people.

These preconditions included (a) researching the

local Aboriginal community; (b) developing net-

works and relationships; (c) nonjudgemental self-

reflective psychological practice; and (d) modifica-

tion of microcounselling and engagement skills.

As part of the REP participants asserted that the

NA therapist should thoroughly first research the

local area and Aboriginal community. This research

might take the form of reading, talking to NA

professionals in the field or, most importantly, the

local Aboriginal people (via the cultural consultant).

This information would provide the practitioner with

a more detailed background of local politics, history,

culture, practices, processes and provide a platform

from which to develop relationships with the

Aboriginal community. These data may also allow

the practitioner to avoid the more obvious cultural

faux pas and navigate a more informed information-

gathering approach when developing relationships

with the Aboriginal community. Similarly, some

authors (e.g., Crawford et al., 2000) have argued

that although reading is an important way to gather

such information, it should be used only as an aid to

understanding. The most relevant and valuable

information is most likely to come from the local

Aboriginal people.

The second step in the REP is actually developing

networks and building relationships with the Abori-

ginal community, families and individuals. Develop-

ing relationships both personal and professional can

afford the NA practitioner valuable insights into

Aboriginal culture. Many of the study respondents

advocated that counsellors develop personal rela-

tionships with Aboriginal people. They highlighted

the fact that most NA mental health practitioners do

not have Aboriginal friends outside of the workplace

and consequently were not exposed to a whole side

of Aboriginal culture. Forrest and Sherwood (1988)

agreed about the importance of establishing such

relationships, but advised against making friends in

the Aboriginal community too quickly. Rather they

recommended that new practitioners are friendly to

everyone and over time form friendships to those

whom they become close. These relationships and

networks provide multiple opportunities for the

therapist to seek assistance and guidance when

working. Such networks may also provide a vehicle

that allows for the development of a critical reference

group that can both reflect and advise on the

interventions proposed by the practitioner (Casey,

2000).

Third, to increase the potential for successful

engagement, the NA practitioner should ensure that

he/she engages in nonjudgemental practice. Judging

Aboriginal cultural beliefs and practices from a

Western worldview can be a barrier that prevents

Aboriginal people from engaging with NA people

(Crawford, 1989; Crawford et al., 2000). Sue and

Sue (1999) argued that the NA therapist must be

both aware and comfortable with the differences of

cross-cultural clients and ensure that these differ-

ences are valued and not negated or judged. Study

respondents repeatedly claimed that Aboriginal

people are very intuitive and can quickly detect

those NA people who are unable to disengage their

Western framework, and those people are most likely

engaged with at a superficial level or avoided all

together.

The fourth precondition pertains to core counsel-

ling skills. Findings suggest that prior to engagement

with Aboriginal clients some NA mental health

practitioners might have to modify some of their

microcounselling and therapeutic alliance skills. In

particular, they highlighted the therapist’s use of

language as a potential problem if polysyllabics and

jargon were used. Many Aboriginal people refer to

this as high language and have trouble following

conversations in which this type of language is used.

Some Aboriginal people may preface a conversation

with a warning to NA mental health workers not to

use high language. According to the study partici-

pants, therapists and counsellors who inadvertently

use such language are sometimes perceived by

Aboriginal people as patronising, ignorant or lacking

respect. These potential problems with language can

be exacerbated when English is not the client’s first

language. It is also important to remember to speak

slowly, to allow time for Aboriginal people for whom

English is a second language to translate what you

are saying into their own language and then back

again in English (Crawford et al., 2000).


It is particularly important that, during REP, the

NA practitioners work with an Aboriginal cultural

consultant. The cultural consultant can be an

extremely valuable source of information because

they can ensure that the practitioner does not offend

any Aboriginal community members during the

critical networking and research component of the

REP. Study participants advocated that the cultural

consultant is generally the best person to organise

meetings for the NA practitioner with other Abori-

ginal community members and stakeholders. Study

respondents felt that it was extremely important that

the role of the cultural consultant was validated and

utilised by the NA practitioner when they were

working with Aboriginal clients. They expressed

concern that cultural consultants are often dismissed

once the NA practitioner gained experience, or was

re-engaged only when cases became problematic.

Ideally, cultural consultants need to be involved in

all engagements between NA practitioners and

Indigenous clients.

Engagement. It is clearly impossible for members of

one culture to fully understand or enter into the

worldview of another. NA therapists can further

compound this lack of understanding if adequate

guides and supervision are not provided when they

work cross-culturally. Authors such as Casey (2000),

Dudgeon (2000b), Dudgeon et al. (1993), Lee

(1996), Pope-Davis and Constantine (1996), Sue

et al. (1996) and Sue and Sue (1999) argue that

although most Australian indigenous people would

prefer to access mental health services from people of

the same culture, this is sometimes difficult to

achieve. The shortage of such Indigenous mental

health services often means that NA therapists

provide services to overcome shortcomings (e.g.,

lack of same-culture counsellors). The authors

maintain that NA therapists can provide a culturally

sensitive service if they follow some basic guidelines.

Further, Dudgeon (2000b) and Casey (2000) main-

tained that therapeutic frameworks suggested by

some authors (Dudgeon et al.., 1993; Sue et al.,

1996; Sue & Sue, 1999) can be enhanced by using

cultural consultants and Aboriginal professional

health networks.

The following model is proposed for NA thera-

pists intending to work with Australian Aboriginal

clientele. The model was developed after a review of

the literature (Boyd, 1993; Dudgeon, 2000b; Ivey,

Ivey, & Simek-Morgan, 1993; Rosen, 1994; Slattery,

1987; Sue & Sue, 1999; Vicary, 2000, 2003; Vicary

& Andrews, 2000, 2001), of the authors’ professional

experience as research and clinical psychologists

working with Aboriginal people, and of the study

findings. This is a 10-step model, which takes the

practitioner from the preparatory stages to interven-

tion closure. The first three stages (self-reflection;

formative preparation; and networking and super-

vision) proposed in the model are consistent with the

REP outlined earlier.

Stage 1: Self-reflection. Practitioners ought to reflect

on their motives for wanting to work with Abori-

ginal people. There must be no hidden agendas

(i.e. working with Aboriginal people for reasons

other than those pertaining to therapy) and the goal

should be to provide a quality and culturally

appropriate service aimed at empowering Aboriginal

clients.

Stage 2: Formative preparation. NA practitioners are

advised to review microcounselling skills and how

these may need modification in an Aboriginal

context. They should develop familiarity with the

role of the cultural consultant so that they might gain

maximum benefit for their Aboriginal clientele. They

may also undertake some form of cultural awareness

training to improve their understanding of Aborigi-

nal culture.

Stage 3: Networking and supervision. The NA practi-

tioner ought to undertake appropriate networking

according to whether one is an independent practi-

tioner or team member. Networking entails building

relationships with Aboriginal colleagues, Aboriginal

agencies and organisations, Elders, professional

peers, the Western society in which one is located

and the Aboriginal communities with which your

clients have membership. Counsellors are advised to

research local history, key policies, identify stake-

holders/gatekeepers and factors that affect the target

client group. NA therapists should yarn with

Aboriginal locals to develop a cultural reality of the

community. This process will also assist in translat-

ing academic cross-cultural information and prac-

tices into practical applications for the field. The

practitioner is strongly advised to develop relation-

ships with the Aboriginal community outside of the

professional role.

When working as an independent practitioner the

therapist ought to seek out persons who could work

effectively as cross-cultural consultants for target

communities (select two or more with a gender

balance). If working in an existing team (e.g.,

government departments), this framework might

already be in place. Utilise the information gathered

from Aboriginal stakeholders to assist in the selection

of appropriate persons. Once this selection has been

made, discuss the choice with the Elders so that it

might be validated.

As part of the networking process, existing

mechanisms for professional and cultural super-

vision need to be explored. If a critical reference


group does not exist locally then the NA therapist

might negotiate with Aboriginal mental health

practitioners to create supervision opportunities. If

it is not possible to establish a critical reference

group then the practitioner might consider using

alternative means such as video conferencing, or

phone supervision and de-briefing. If a cultural

consultant has been contracted, there ought to be

agreement on the reciprocal nature of the cotherapy

arrangement and the competencies derived from the

arrangement. Part of this agreement may include a

supervisory component in which the cultural con-

sultant provides constructive reflection upon the NA

counsellor’s practice.

Once these three steps have been completed the

NA practitioner is now prepared to undertake

assessment and therapy with Aboriginal clients. It

is crucial for NA therapists to work alongside

cultural consultants when working with Aboriginal

people. All of the work described in the remainder of

this model assumes an egalitarian cotherapeutic

relationship between the NA practitioner and Abori-

ginal counsellor.

Stage 4: Referral. Therapists are advised to be

familiar with the processes used to register referrals

within their service. Often in the field, referrals are

lodged by phone or verbally and a system needs to be

developed for documenting informal referrals. The

willingness of the client to take up the referral must

be examined carefully. This is an important con-

sideration because situations may arise where a

family member or health professional makes a

referral out of concern for a person without inform-

ing the person of their actions. Even if the individual

has been informed of the intent to refer, they may

have reconsidered the option since they were first

approached. They may be anxious or ambivalent

about the referral.

Western practitioners ought to negotiate with their

team and consultants as to what priority should be

given to the referral (i.e., is this crisis intervention or

can it be placed on a waiting list until space appears

on caseloads?). If the referral has been made to

satisfy the requirements of another agency (e.g.,

Department of Justice) and the referral is accepted,

then a negotiation of realistic time frames should

take place in order to best serve the client.

Some clients may already be engaged with other

service providers who are assisting with their case

management. It is important in these situations that

a holistic approach is taken to case management and

that negotiations with the client are used to ascertain

what agency is the most appropriate to handle the

intervention. If it appears that there would be

duplication of service delivery or that the needs of

the client could be better met by another practi-

tioner, including traditional counsellors, then this

should be discussed with the client.

Stage 5: Research. The NA practitioner should

gather a client history from both the client and, if

possible, the referrer. Information may also be

obtained from cultural consultants. Preferably all of

these avenues should be explored. With the client’s

written permission, contact should be made with

agencies and workers who may have relevant

information (Vicary & Dudgeon, 2000).

Stage 6: Potential limiting factors. The practitioner

and the cultural consultants should discuss barriers

that may impede an effective intervention with the

client (e.g., gender issues, age concerns, cultural

factors and family dynamics). In the development of

case management plans it is important to both

acknowledge and accommodate the diversity of

cultural beliefs and practices. Acknowledging that

clients will demonstrate different ways of under-

standing and responding to given situations will

enable the practitioner to adopt flexibility in the

approaches that they take.

Determine if the client is willing to be seen in their

community or would prefer to come to the thera-

pist’s work place. Clients sometimes feel more

comfortable being seen in a place other than their

community. Access to transport and environmental

factors may limit the preferred options and these

should be addressed. Identify where the therapy

team (cultural consultant and NA practitioner) and

client will feel safe to meet, and where the client will

be at ease to share information. This should be

negotiated prior to the first contact between the team

and the client. Generally the cultural consultant may

be in the best position to undertake this negotiation.

Additionally, the cultural consultant can explore the

issues of the therapist’s age or gender with the client

to determine if this is likely to be an impediment to

establishing rapport. Therapy teams should identify

the client’s requirement for a support person (e.g.,

family members) and negotiate with the client as to

who else should attend the meeting and how they

would like this organised.

NA practitioners should avoid jargon and poly-

syllabic words. They should consider the need for an

interpreter and negotiate with the cultural consultant

to discuss this issue with the client. The cultural

consultant may be comfortable with the dual role of

consultant and interpreter if this is appropriate. The

NA practitioner should be aware that an Aboriginal

client might be reluctant to have a family member act

as interpreter because this may compromise con-

fidentiality. Clients may be suspicious of how the

information they provide during therapy will be used

and with whom the information may be shared. This


may relate to previous breaches of confidentiality,

which may have had negative repercussions for the

client.

The practitioner needs to be aware of community

events such as deaths and Law business. Contact

(e.g., telephone) must be made with the community/

family to negotiate an appropriate meeting time. The

community Chairperson or coordinator should also

be asked if the proposed visit is appropriate. They

ought to be informed of the nature of the visit and

who will be visiting. If there is a degree of

uncertainty, clarification should be sought prior to

the visit.

Stage 7: Contact. From negotiations with the client,

the therapy team should identify who will be

involved in the initial contact and provide all parties

with details of the time and location of the meeting.

Negotiations with the client about the venue for the

appointment and arrangements to make this a safe

and comfortable environment should be finalised.

Although the client may have been actively involved

in the process to date, the reality of the meeting may

prove difficult for the client and they may withdraw,

or become anxious or depressed. The therapy team

may need to consider a range of strategies to assist

such clients to engage (e.g., engage in an activity

such as fishing and develop a relationship that is not

perceived as professionally based). Many clients may

be ambivalent about engaging until information

derived from the vouching process is obtained.

During engagement the NA practitioner should be

careful to listen to what the client is saying without

interruption. Microcounselling skills should be

modified because some of these techniques may be

considered rude by Aboriginal people (e.g., reflective

feedback). Simple questions should be asked, and

the client given time to respond. NA therapists will

need to become accustomed to silences and not

attempt to rush the process while the client is

thinking.

Stage 8: Therapeutic options/contact. The therapy

team should explore the range of therapeutic inter-

ventions that are available and that are proven to be

effective with Aboriginal clients. Although Western

practitioners may have a preferred style of operating

or have a repertoire of interventions, it is important

to be open to the use of a range of approaches.

Suggestions made by the cultural cotherapist may

provide information about the client’s preferred way

of interacting and expectations of therapy.

It is vital that the team shapes the intervention to

the needs of the client, and if this is not possible it is

the team’s responsibility to refer the client to

someone else. For example, a client may wish to

work within a Christian framework or with a gay

counsellor on sexual identity issues. Similarly, the

mental health issues may be related to cultural or

spiritual factors and this is best referred to a specialist

within the Aboriginal community. Some clients may

have had previous therapeutic interventions that they

have found beneficial. The team should invite

discussion on what has worked for them in the past.

It is also important to ensure that therapeutic contact

is defined as a reciprocal partnership process and

that the team’s goal is to empower the client through

egalitarian client-centred approach.

Stage 9: Follow-up. This stage requires the involve-

ment of clients and stakeholders in addition to the

therapeutic team. NA practitioners should be cog-

nisant that clients may be reluctant to directly

provide negative feedback and that you may need

to approach a third person for feedback. For

example, a client may not be able to express their

negative or positive feedback to the practitioner.

However, they may express these thoughts to the

referrer, who may in turn pass these on to the

practitioner if requested. Clients may also need to

talk to the cultural consultant if they are concerned

about aspects of the therapeutic process.

Stage 10: Evaluation. Evaluation is an ongoing

process, and there may not be immediate positive

outcomes. Many clients will come from highly

dysfunctional environments and goal setting needs

to be realistic given the context of the environment to

which they will be returning. Some interventions

take some time to work due to the chaos many

clients experience in the family and community life.

The therapy team need to be both supportive and

patient during this time.

When undertaking an evaluation of the service

provided, there are human limitations (bias) to be

considered. Many of these biases may be found in

both the Aboriginal and NA populations. For

example, a client may not want to appear ungrateful

regarding the service provided, or they may mis-

represent what they have achieved so as not to

disappoint the service provider. There are some

limitations in the objectivity to evaluation.

It is worth considering the ripple effect of the

intervention as part of the evaluation process. For

example, if a client is pleased with the outcome they

are then likely to endorse (vouch) the service to

others. Clients who have not fully engaged need to

be told that although there may be closure on this

particular intervention, they are able to re-engage

once they have reflected on the process and/or when

their situation changes. At the point of re-engage-

ment, useful feedback can be gained as to what had

contributed to the lack of full engagement at first

contact. If the intervention has not proven beneficial


to the client then it is useful to suggest other

treatment alternatives provided by other practi-

tioners or organisations.

Clients who re-engage (or whose treatment needs

alteration) will require a review of their current

treatment needs and possible therapeutic interven-

tions. Whether a client is seen for one session or

whether they terminate a therapeutic relationship

after many sessions, the process of closure is an

important one. An evaluative review of each inter-

vention allows the client time to reflect on what has

been discussed and clarify issues as needed.

Conclusion

Findings from this study have broadened NA knowl-

edge of Aboriginal conceptualisations of mental

health. The results have clearly demonstrated the

negative perceptions that Aboriginal people have

towards the Western mental health system and to

practitioners. Importantly, insight has been provided

into the culturally appropriate hierarchy of traditional

treatments that many Aboriginal people access prior

to Western treatments. The findings also suggest that

NA counsellors can work more effectively with

Aboriginal clients once certain preconditions (e.g.,

use of cultural consultants, steering groups) are met

and culturally sensitive practices implemented.

To ensure that culturally appropriate counselling

approaches are adopted, there are major adjustments

required to tertiary education, psychotherapeutic

practice, research and social policy. Without these

alterations and the political will to ensure that

changes are consolidated and maintained, it is

doubtful that the status quo for Australian Abori-

ginal people seeking culturally appropriate mental

health services will alter.

Acknowledgements

Sincere thanks to all of the Aboriginal people

involved with the project. Without their support

and guidance the study would never have been

completed.

Note

1 For the purpose of this paper the word Aboriginal

will pertain to Aboriginal people as Indigenous

Australians (Swan & Raphael, 1995).

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Documents

Western psychotherapeutic practice: Engaging Aboriginal people in culturally appropriate and respectful ways