SCHOOL OF PUBLIC HEALTH & COMMUNITY MEDICINE THE UNIVERSITY OF NEW SOUTH WALES SYDNEY AUSTRALIA

THE WHAT, WHY AND HOW OF THE WHAT, WHY AND HOW OF KOORIE WELL-BEINGKOORIE WELL-BEING

DEVELOPING CULTURAL SAFETY AND CULTURAL EASE TO STRENGTHEN

FAMILIES

MURU MARRI INDIGENOUS HEALTH UNIT

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THE WHAT, WHY AND HOW …THE WHAT, WHY AND HOW …

What do we know of the effects of

mental distress on Koorie families? Why is it so hard to lighten the burden

of community distress … to break

the inter-generational cycle? How can service providers and

organisations make a difference?

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HOW, HOW, IN PARTICULAR …IN PARTICULAR …

Can cultural safety and cultural ease

bring about sustainable change in the way

both people and organisations work? Do you effectively engage Koorie

communities? Can all this help strengthen Koorie

families?

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THE WHAT …THE WHAT …

What do we know of the effects of

mental distress on Koorie families?

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INDIGENOUS MENTAL INDIGENOUS MENTAL DISTRESSDISTRESS Vic: 2 x Non-Koori rate of ‘Higher Mental

and Behavioural Disorders’* NSW: self-reported ‘mental distress’

almost 2 x Non-Koori rate** WA children: High risk of significant emotional/behavioural difficulties -

Nyoongah 24% > Wajella 15% ***

* Aboriginal Affairs Victoria ** NSW Health *** WAACHS

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‘‘NOISE’ IN THE SYSTEMNOISE’ IN THE SYSTEM

Reports show a high level of generalised, or non-specific mental distress*

Clear Indigenous mental distress diagnoses, or ‘signals’, hard to assess owing to background ‘noise’

Example of Post-Natal Depression

* Gavin Stuart, former epidemiologist for NSW Health

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JUST WHAT IS THIS ‘NOISE’? JUST WHAT IS THIS ‘NOISE’?

Dispossession – land, language, culture,

economic base → grief and loss ‘Stolen Generations’ Trans-Generational Trauma Racism/discrimination and ‘Clayton’s’

apartheid

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INDIGENOUS MENTAL INDIGENOUS MENTAL DISTRESS: A LAYER MODELDISTRESS: A LAYER MODEL

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““PSYCHOLOGY DOESN’T PSYCHOLOGY DOESN’T HAVE THE TOOLS … ”HAVE THE TOOLS … ”

to deal with catastrophe* complex Post-Traumatic Stress Disorder** complicated grief - “People with

complicated grief are basically stuck in a state of chronic grieving”***

* Erika Apfelbaum ** Derek Silove *** Paul Boelen

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THE WHY …?THE WHY …?

Why is it so hard to lighten the

burden of community distress … to

break the inter-generational cycle?

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GRIEF AND LOSSGRIEF AND LOSS

The losses from colonisation are

multiple Loss is an on-going Koorie

experience It’s both profound and pervasive

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‘‘STOLEN GENERATIONS’STOLEN GENERATIONS’

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‘‘STOLEN GENERATIONS’STOLEN GENERATIONS’

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INCARCERATION AND INCARCERATION AND ‘STOLEN GENERATIONS’‘STOLEN GENERATIONS’ One third of all Aboriginal inmates in

NSW had been removed from their parents

as children 31% of female Aboriginal inmates in

NSW, and 21% of male, reported that their

parents had been forcibly removed from

their families as children*

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TRANS-GENERATIONAL TRANS-GENERATIONAL TRAUMATRAUMA Holocaust literature – Yael Danieli Koorie research - Pat Swan /

Beverley Raphael, Jane McKendrick Critical Psychology – Erika Apfelbaum Critiques of Bio-Psychiatry –

Peter Breggin

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T-G TRAUMA RECOGNISEDT-G TRAUMA RECOGNISED

DVA programme* for children - criteria: Both parents experiencing a mental illness

and /or alcohol /drug abuse problem One parent (particularly a mother)

experiencing a mental illness and/or alcohol/drug abuse problem

A father who has identified his health as ‘very poor’

* Vietnam Veterans Counselling Service Vietnam Veterans Sons and Daughters Project Plan

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T-G TRAUMA - NOT ‘MENTAL’T-G TRAUMA - NOT ‘MENTAL’

Psychobiology / Body memory of

trauma – Bessel van der Kolk Psychoneurobiology / Developing brain

& trauma – Bruce Perry, Alan Schore Trauma and Psychosis – John Read

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STATES BECOME TRAITS STATES BECOME TRAITS

Dissociation (‘freeze’) If a child dissociates in response to severe

trauma and stays in that … state for … sufficient … time, [they] will alter the homeostasis of the systems [involved]…

↑ dissociative/somatoform disorders, anxiety, major depression

* Bruce Perry, 2001

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STATES BECOME TRAITSSTATES BECOME TRAITS

Hyper-arousal (‘fight’ or ‘flight’) If the child exposed to violence uses a …

hyper-arousal response, the altered homeostasis will be in different neuro-chemical systems

↑ persisting hyper-arousal symptoms / disorders: PTSD, ADHD, conduct disorder

* Bruce Perry, 2001

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PREGY. / EARLY YEARS - PREGY. / EARLY YEARS - SUPPORT CRITICAL SUPPORT CRITICAL Exposure to violence or trauma alters the

developing brain Consistent, moderate stress → resilience Unpredictable or chronic stress → deficits

in function / vulnerability to future stressors*: ‘Living barefoot … surrounded by broken glass’

* Bruce Perry, 2001

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EFFECTS OF RACISMEFFECTS OF RACISM

Racism is a major determinant of health

and a driver of inequalities in health*

* Ricci Harris et al, 2006

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EFFECTS OF RACISMEFFECTS OF RACISM

Consistent relationships [have been found] between self-reported discrimination and … poorer mental health outcomes*

The literature suggests a robust link between self-perceived discrimination and mental health**

* Ricci Harris et al, 2006** Gee, 2002

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EFFECTS OF RACISMEFFECTS OF RACISM

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COMBATTING RACISMCOMBATTING RACISM

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‘‘CLAYTON’S’ APARTHEIDCLAYTON’S’ APARTHEID

What are the contemporary effects of

keeping Aboriginal Australia side-lined

for generations?

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EFFECTS ON IDENTITYEFFECTS ON IDENTITY

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PERMISSION TO MARRYPERMISSION TO MARRY

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CEASE TO BE AN ABORIGINECEASE TO BE AN ABORIGINE

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THE HOW …THE HOW …

How can service providers and

organisations make a difference?

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AN INTEGRATED APPROACHAN INTEGRATED APPROACH

Cultural Competence

Cultural Ease

Cultural Awareness

CulturalSafety

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UNSAFE CULTURAL PRACTICEUNSAFE CULTURAL PRACTICE

… comprises any action that diminishes, demeans or disempowers the cultural identity or well-being of an individual.*

* Nursing Council of New Zealand, 2005

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CULTURAL SAFETYCULTURAL SAFETY

More than simply having some cultural

awareness/sensitivity* Requires the service provider to let go

some ‘power’ in the relationship with the

client**

* New Zealand Psychologists Registration Board, 2006

** Aekins, 2006

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CULTURAL SAFETYCULTURAL SAFETY

The client determines what’s comfortable

– the service provider looks for guidance

as to how to provide the service The service provider professional is

encouraged to reflect on their own cultural

identity and how this plays out in the way

they work with the client

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CULTURAL EASECULTURAL EASE

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NOTNOT CULTURAL EASE CULTURAL EASE

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HOW TO MAKE A DIFFERENCEHOW TO MAKE A DIFFERENCE

Strengthen resilience – personal and cultural Keep a de-Othering perspective Cultural safety – make it a service priority Cultural ease - use Aboriginal protocols/ways Build environments for change – develop real

engagement with local community Extended advocacy – Political is the

Clinical

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STRENGTHEN RESILIENCESTRENGTHEN RESILIENCE

Culture and health Connection to culture, language, land

‘protective’ of well-being* Notion of cultural resilience**

* Jane McKendrick

** Iris HeavyRunner and Kathy Marshall / Tracy Westerman

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STRENGTHEN RESILIENCESTRENGTHEN RESILIENCE

Enculturation is a resiliency factor in development …

Spirituality reported by adolescent students was related to competence …

[Other studies show] links between spirituality and/or enculturation and wellness and/or resilience

* Joyce Strand and Thomas Peacock, 2002

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Being Being ootherther

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Being Being OOtherther

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BEYOND THE PALEBEYOND THE PALE

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INDIGENOUS AUSTRALIAN INDIGENOUS AUSTRALIAN APPROACHES TO LISTENINGAPPROACHES TO LISTENING

Dadirri

“Inner, deep listening and quiet, still awareness … something like what you call contemplation.” (Miriam-Rose Ungunmerr-Baumann)

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Indigenous Australian Indigenous Australian Approaches to ListeningApproaches to Listening

Dadirri

Listening with your ears and heart*

* Judy Atkinson, after Miriam-Rose Ungunmerr-Baumann

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INDIGENOUS AUSTRALIAN INDIGENOUS AUSTRALIAN APPROACHES TO LISTENINGAPPROACHES TO LISTENING

Ngara“Listen, hear, think … (Eora, the Sydney language) to listen is simultaneously to reflect and become self-aware.”*

* Paul Carter

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Indigenous Australian Indigenous Australian Approaches to ListeningApproaches to Listening

Ngara Listening requires something of you … you need to complete the circle. Hearing should lead to action.*

* Koori Peak Organisation Board Member

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INDIGENOUS AUSTRALIAN INDIGENOUS AUSTRALIAN APPROACHES TO LISTENINGAPPROACHES TO LISTENING

Binang Goonj

“They hear, but they don’t listen.” (Bidjara language, south-west Queensland)

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INDIGENOUS AUSTRALIAN INDIGENOUS AUSTRALIAN APPROACHES TO LISTENINGAPPROACHES TO LISTENING

The Role of Silence

"If you cannot understand an Aboriginal person's silence, then you will never understand their words" (Uncle George Tongerie, Elder from South Australia)

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FOR US, FOR US, LISTENINGLISTENING INVOLVES INVOLVES

More than ‘hearing’- includes self-

reflection /contemplation

‘Listening’ to the silence … to what’s

not being said … to what’s being

said non-verbally

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INDIGENOUS LISTENING IS INDIGENOUS LISTENING IS CONNECTION CONNECTION →→ RELATION RELATION Indigenous cultures built on kinship Everyone’s connected - somehow Through ‘deep listening’, and appropriate

self-disclosure, you become part of that

person’s / or community’s universe Now people can deal with you – safely –

and you with them

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CULTURAL SAFETY / EASECULTURAL SAFETY / EASE

↑ training in Koorie child/family well-

being Prioritise cultural safety Build a service that’s comfortable with

Aboriginal protocols and at home with

Aboriginal ways

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BUILDING ENVIRONMENTS BUILDING ENVIRONMENTS FOR CHANGEFOR CHANGE

Improving Koorie well-being means Building environments for change,

cooperatively, with communities Consultation beyond lip service – that involves

full community participation in planning Ready-made / one-size-fits-all solutions fail

- flexibility offers more chance of success … have your ‘cloth’ at hand, but cut it to fit

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REAL COMMUNITY ENGAGEMENTREAL COMMUNITY ENGAGEMENT

Little ‘r’ respect What do I know about the people I am

working with? How can I find out more? Meeting people in their own reality builds

trust and confidence

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KOORIE WAY - COMMITKOORIE WAY - COMMIT

Take time to build real relationships – the

‘slow road’ may be the fastest way to get

there So … get involved for the long haul Koorie people/ communities want a

partner who’s ‘clued-in’ and committed

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BUT … ALL THIS IMPLIESBUT … ALL THIS IMPLIES

Personal challenge

To existing comfort zone Professional challenge

To models of professional distance and

non- disclosure

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BUT … ALL THIS IMPLIESBUT … ALL THIS IMPLIES

Organizational Challenge

Mandates organisational change Political Challenge

Strong advocacy is politically risky

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The Political The Political IsIs The Clinical The Clinical

Australian Govtl. denial of contemporary

consequences of past practices leads to: inequitable, ineffective policy under-funding of services mainstreaming of services / lack of

culturally-safe services

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The Political The Political IsIs The Clinical The Clinical

History of inadequate govt. action

mandates new forms of proactive action Considered, sustained lobbying on behalf

of child/family need is part of duty of care

- importance of extended advocacy

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The Political The Political IsIs The Clinical The Clinical

Extended Advocacy – be informed and bold Insist government policy founded-on

contemporary effects of loss and TGT Insist initiatives be funded according to

need, are sustainable Insist anything else is a violation of our

duty of care