Editorial
On social justice
Graham Martin OAM
Professor of Child and Adolescent Psychiatry, Discipline of Psychiatry, University of Queensland, St Lucia QLD
PP: 084 - 087
Article Text
Before moving to Queensland three years ago to take up the Chair of Child and Adolescent Psychiatry, I had worked for sixteen years in a clinical organisation in South Australia which was passionate about social justice, community focused to a fault, with some experience in early intervention, prevention and mental health promotion before they were on the national agenda. Client centredness and a solid philosophy based on systems thinking and family dynamic approaches, meant that within our management process we were always searching for ways to meet the expressed community need while matching it to our clinical abilities. An example of this was when no money was available for rural services. We simply decided to allocate money from elsewhere in the budget to set up skeleton rural services with monthly visiting specialists to support on-the-ground staff. With the obvious success of the program (and with ever increasing factual knowledge of the real need of rural communities in our patch), we were able to persuade the state government to fund the extra positions needed to fully meet the need. In putting the cart before the horse, that is in providing the services before we had fully fledged operational plans and the attached new financial resources, we were never able to recoup the money we spent in those first few years. Despite this we always seemed to come in on budget. And we had a fully-fledged 'country team' operating out of three rural hubs, with a team leader dedicated to making it all work. The city teams and their services suffered a bit, the visiting clinicians were asked to break a golden rule and work out of four and sometimes five centres rather than the expected three and were often exhausted after a frenetic tour of a country region, and occasionally we sailed close to the political wind. But it worked; we had translated our beliefs and our passion into action. The fact that it was at some extra cost to us as individuals, and our overall service, was irrelevant.
A part of this story is relevant to this current issue of AeJAMH. In developing services to the Riverland, we became aware from a number of sources that the Aboriginal community consisted of some 2500 people, had a high level of mental health problems, and was provided with almost no relevant service. An opportunity arose to employ an Aboriginal person who was still completing his training; we were excited at the possibilities and leapt to employ him in a specifically created position. Of course we employed him at a rate similar to other non-Aboriginal staff in the service, after all we expected him to become a regular team member and fulfil a role equivalent to our other workers. This led to uproar. We were abused by several sources claiming we were undermining the current pay scales, and setting up unrealistic expectations for other Aboriginal health workers and their services. The assimilation into the service was also hard on both sides. Our expectations were probably set too high, bridging to the Aboriginal community proved far more complex than we had expected, and supervision and mentoring were hard because we did not have a wide range of Indigenous Mental Health Workers to call on. The local small rural team was very welcoming and supportive, and had worked hard to gain a sense of local indigenous issues. Certainly our worker stayed the course; but at some cost to him and probably all concerned. Our less than perfect start led to the subsequent development of a full time position, which was filled by a fully trained worker who built well on the previous processes. We all survived what was a very steep learning curve. Did we assist the local Aboriginal community? Yes and no! We did improve pathways to care somewhat, but with both of our workers being male, and both from differing tribal backgrounds, the entry to the community was complex and fraught with misunderstanding. Women's business was not well dealt with, and suspicion and reticence were a daily battle. More than that, there were issues raised which were perplexing, or at the time made little sense; fifteen years of reading and experience later (and having had the opportunity to read the papers in this issue of AeJAMH), I find myself understanding things a little better.
As an example, let me share one story. Our second worker felt it was crucial for several of the management team to visit the community in question and meet with the Elders. This sharing of history, views and beliefs in the community hall went well overall. Afterward, standing outside in the sunshine with one of the male elders, there was a lengthy pause. Then he said: 'Of course the problem with you white people is that you think about the body, and you think about the mind, but you never think about the spirit'. The phrase sat with me for a long time, and began to make some sense as several of us at Flinders University, including an Aboriginal project officer, later began to think through the development of a master's level course on Social and Emotional Wellbeing - aiming to provide education and training for Indigenous health workers. However, it was not really until quite recently that the evidence for spirituality in the context of both understanding, and therapy, began to be presented at national conferences. For me this culminated last year in a conference I convened in Brisbane on 'Spirituality and its Place in Suicide Prevention', hosted by SPA (Suicide Prevention Australia). The Indigenous input throughout was prominent and influential, apart from being immensely moving. So have we advanced much?
Currently, I am involved with a clinical service in Brisbane which sees itself as having some responsibility statewide - especially where gaps in services need to be filled. Recently we have begun some supportive consultation services to far north Queensland - no extra funding of course, just some commitment to social justice. There are services which have developed at a local level, largely supported by Ernest Hunter and staff from his service from Cairns. But some expert help was thought to be needed in Child Psychiatry. We are doing the best we can do, with the resources we have at our disposal, but when I reflect on what we are doing in the light of having read this issue of AeJAMH, I am appalled at what might be called our 'arrogance'. A senior child psychiatrist visits one of three centres, for a week each, to support local staff and to do some direct clinical work where asked. In between, there is availability of videoconferencing and email consultation. Do we meet the requirements suggested by Tracy Westerman in her paper in this issue? I fear nowhere near all. How do we work with local staff? I know the people concerned and they are all sensitive, with some local knowledge, and with deep respect for Aboriginal and Torres Strait communities. But do they meet the standards suggested by Tom Brideson in his two papers in this issue? I fear we have a way to go. We will learn, and now we will consider the issues raised here and adopt what we can. We are at this time providing so little really, but it is a start. And my experience from South Australia suggests that in time we will have fully funded resources available, be fully trained and well supported.
This issue of the AeJAMH is part of Auseinet's commitment to Indigenous mental health, particularly in the area of prevention and mental health promotion. We are immensely grateful to Tracy Westerman who has acted as Guest Editor for the issue. It is fitting that such a powerful, thought-provoking, and challenging issue marks the end of our third year of publication; it reminds us that we still have a lengthy journey ahead if we are to advance mental health for all Australians in a context of Social Justice. Given we have got to '3', I would like to pay tribute at this point to Lou Morrow who began the journal as our first manager, and to Anne O'Hanlon who has continued to raise the editorial standards of the journal and seen it to the point where we are now abstracted by PsycINFO! I also thank Jennie Parham for her ongoing support, and all the assessors who give so much of their time freely. Thank you.
As I have said, this issue is challenging. Ernest Hunter provides a broad overview of the history, and recent changes in the sociopolitical context. In a typically powerful style, he reminds us of how policy has affected the development of services, how complex the issues are in developing services which acknowledge the learned wisdoms of the western traditions of psychiatric care, but are also sensitive to the learned wisdoms of Indigenous communities. He reminds us that we are involved in a struggle to grow away from the separateness and tensions 'between commonwealth-funded, local community-controlled organisations, and state-based mental health services which adhered to conventional understandings and were, generally, defensively dismissive'. Further we are reminded of the 'critical importance of the social determinants of health'. Ultimately he challenges us as Australians to understand that mental health services will never be able to operate successfully unless we are 'aware of particular cultural practice', but at a higher order get the sociopolitical context right.
Tracy Westerman provides a guest editorial which is thoughtful and erudite, yet offers solutions and points the way to possibilities for change in the clinical arena. The advice about the use of cultural consultants is timely, the need for attainment of cultural competence sensible, and the recommendations for cultural supervision both novel and obvious at the same time. She points out that there are 'few published examples of effective preventative programs or therapeutic interventions with Indigenous people', and a 'lack of empirically grounded conceptual frameworks that have proven their efficacy with Indigenous people with specific mental health issues. But if we work our way through the idea of 'cultural competence as eleven different counselling competencies', solutions for effective engagement emerge, as do appropriate culturally sensitive clinical as well as preventive interventions.
Tom Brideson's guest editorial is slightly tongue in cheek, but the humour cuts through our defences to force us to acknowledge the difficulties traditional services have in accepting and working with trained Aboriginal Mental Health Workers. His use of the American Psychiatric Association's DSM-IV is exquisite. But his points around limited recognition, and undervaluing, of the role of the Aboriginal worker leading to stress, frustration and limited opportunities are cogent.
Vicary and Westerman's interviews with Aboriginal people expose very well the deficits in services. They balance the equation by suggesting that on the one hand, more effort needs to be spent in educating Aboriginal people about mental illness and overcoming stigma about seeking assistance, but on the other hand a wide range of issues must be dealt with by therapists in services. An interesting issue raised is that Aboriginal clients need to be heard, and also want to have a practical solution provided for their problem, and may not want to return for more than one visit. This paper, like Westerman's editorial is full of clear, sensible suggestions for practice.
Petchkovsky and colleagues' paper looks at some of the survivors of the 'Stolen Generation'. It describes the long term and ongoing symptomatology of a group of nine adults, and is a sensitive, thorough, poignant and, at times harrowing, account. And these are the survivors. A strong case is made for these people being severely traumatised, yet sociopolitically and legally there is no recourse or, if there is, it is too hard to meet requirements of western law. Another strong case is made for dealing with the ongoing needs for therapy of these people. The paper is accompanied by two delightful and meaningful paintings which depict indigenous understandings of the working of the mind.
Some of what is presented in this issue may seem to be 'just too hard' for western trained practitioners. However, there is clearly a need for those willing to cross the bridge to meet a social obligation, to immerse themselves in Aboriginal culture, and take the advice available to begin to solve the immense problems which remain. If it is too hard, then the paper by Brideson and Kanowski suggests an alternative way to solve the problem - development of large numbers of Aboriginal Mental Health Workers. The paper describes the approach the Djirruwang Aboriginal and Torres Strait Islander Mental Health Program at Charles Sturt University from which a large number of graduates have now emerged successful 'with consistent skills, knowledge, values and attitudes of like-minded mental health professionals, whilst maintaining a deep sense of cultural integrity'. The serious issue of the paper, though, is not the detail of the course (which is made available), but the obligation on the rest of us to provide respect and recognition for students and graduates of the Program, and 'the need for professional organisations and service management and staff to take responsibility in their responses to Aboriginal mental health issues'.
Finally, Terri Elliott-Farrelly reviews the evidence on Aboriginal suicide in the context of the argument for an Aboriginal suicidology. Having considered facts and figures to do with both suicide and suicidal behaviours, she reviews risk factors, drawing on Colin Tatz's work as well as others in acknowledging those factors which may have special significance in Aboriginal suicide; 'a lack of a sense of purpose in life; a lack of publicly recognised role models and mentors outside of the sporting realm; the disintegration of the family and lack of meaningful support networks within the community; sexual assault; drug and alcohol misuse; animosity and jealousy evident in factionalism; the persistent cycle of grief due to the high number of deaths within many communities; and illiteracy, which results in exclusion and alienation'. She considers the cultural meaning of methods of suicide, and finally offers possible preventive strategies which may be culturally appropriate.
This issue of AeJAMH is at times not comfortable to read. It challenges us, and the writing of many of the authors gets through our defensive guard. Good.
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