The philosophy around the development of an Indigenous Australian specific psychological service and discuss the obvious value with an approach which is based on extensive community engagement, ongoing validation of models and services, and importantly ensuring that a rigorous research methodology is applied to all aspects of service provision. Indigenous Australians have amongst the highest rates of mental ill health worldwide, but continue to have the lowest levels of access to mental health services. Presentation by Dr Tracy Westerman, Managing Director, Indigenous Psychological Services, Western Australia at the 2009 SPINZ National Symposium: Culture and Suicide Prevention in Aotearoa: http://www.spinz.org.nz/page/108-events-archive+spinz-national-symposium-2009+symposium-coverage

1. Is Best Practice Really Elusive when
working with Indigenous populations?
Dr. Tracy Westerman
Managing Director, Indigenous Psychological Services
SPINZ National Symposium, 2009,
Wellington, NZ

2. Who am I

3. Overview of IPS
IPS CORE BUSINESS
Community Organisation
Psychological
Training Research Prevention Cultural Change &
Assessment
Programs Development
12 Mental Health Recruitment &
Brokerage Services ADHD Suicide Prevention
specific packages Retention Services
12 packages
Forensic, cognitive focusing on the Suicide Mediation & Comprehensive
& compensation retention of Prevention Conflict Resolution Audits
Indigenous people
4 Indigenous Indigenous specific Development of
Trauma & Critical
Specific assessment & Mental Health
Incident
Intervention intervention operational plans
Indigenous specific
Anger Management
E-learning workforce
Parenting skills
development

4. A few dilemmas to highlight the
problems with mainstream approaches to
suicide prevention
• A traditional Aboriginal Australian is
charged with the statutory assault of a
12 year old girl from an Aboriginal
community – he is sentenced to two
months in prison on the basis that he
argues that the girl was ‘promised’ to
him as part of a traditional marriage.
The girl goes on to attempt suicide
• Abuse or Culture?

5. And Mainstream approaches to Mental
Health
• An Aboriginal man is on trial for the
murder of his traditional wife. He says
that on the days leading up to the event
he was being ‘sung’ (cursed) by cultural
law men. The singing involved command
hallucinations. He has no history of
violent behavior.
• Psychotic or culture-bound?

6. Overview of Presentation
1. An overview of the current mental
health status of Aboriginal Australians
2. Identify the priorities in developing
best practice methodologies in mental
health service delivery for Aboriginal
people
3. The work of IPS in developing models
of effective practice in Indigenous
mental health (and suicide prevention)

7. The State of Play
• Misdiagnosis, overdiagnosis and
underdiagnosis of mental health issues
1. Cultural Triggers not identified in
mainstream assessments – but can we
measure the relevance of culture?
2. Practitioner impacts – judging the absence
or presence of disorder
3. Normality seen as abnormality – e.g. being
sung/cursed, having spiritual visits of
deceased loved ones versus psychosis
(culture-bound syndromes)

8. What the current day looks like….
1. Less likely to access mental health services
2. Less likely to be identified as having a
mental health problem – by services and
community – “that’s just the way he is”
3. More likely to engage for shorter periods
and at chronic levels
4. More likely to be treated with medication
than any other form of therapy
5. Isolation and treatment access –
accommodation is greater
6. External attribution belief system and
problems
7. Stigma regarding mental health

9. What role history has played…
• Population of over 1 million prior to 1788,
declined to 30,000 by the 1930’s
• Social policies
• Assimilation until 1972
• Exclusion from education until 1960’s
• Exclusion from parenting support benefits until
1970s
• Citizenship rights in 1960’s
• Classified under flora and fauna until 1960’s
• Prohibition until the 1970s

10. And continues to play…..
• Aboriginal people constitute 2.2% of the
Australian population of approx 20 million
• Most disadvantaged on every social indicator
• Life expectancy 20 years less than NA
(average is mid 50)
• Infant mortality is three times that of NA
Australia
• Fourth world conditions
• Denial of History (refusal to say sorry) under
Howard Liberal Govt from 1996 - 2007
• Validation of trauma – why ‘sorry’ was not
the hardest word after all
• How this maintained trauma and difficulty
in healing

11. Impacts of Stolen Generations
• Acculturative stress and marginalisation
• Premature death and compounded grief
• Forcible removal – loss of parental
models and practices
• Cultural parenting strategies are seen
as deficient by mainstream
• Removal leads to difficulty in
developing healthy attachments
• Ability to respond to the range of
positive and negative emotions in our
own children

12. Impacts of Stolen Generations
• Intergenerational Impacts
• Mental illness and genetics/environment
• More likely to experience intra-familial
abuse leading to greater risk for PTSD and
difficulty with healing
• Changes to cultural practices
• The role of payback (customary law) in dealing
with non-traditional issues (i.e. assault and
suicides)
• Sorry time and cultural grieving for suicide

13. How this translates
• Rates of mental ill health
• suicidal behaviours,
• depression,
• self-harm,
• PTSD???
• Dual diagnosis - alcohol and drug useage

14. What are the priorities
in Aboriginal mental
health?

15. Priority 1: Reliable and Valid
Assessments & Tests
• Impacting on
• Are the assessments culturally valid?
Construct? Face? Cultural?
• Does the assessment take into account the
cultural relativity of behaviour? E.g of
ADHD; spiritual visits
• Evidence for trends in tests with minority
populations e,g. Depression measures;
MMPI; CBCL
• Different symptom base for disorders
across cultures (Westerman, 2003; Allen,
1998; Manson, 1995)

16. Priority 2: Improving on access to
appropriate services
• Cultural Competence is ill defined and
not measurable becoming the ‘poor
cousin’ to clinical competence
• Leads to Organisations grappling with how
to embed cultural competence in all aspects
of service delivery
• No clear pre requisite skills in working with
Aboriginal people in a mental health
capacity

17. Problem: Inequities in research and
Indigenous specific mental health
intervention programs
• Prevalence rates range from 1.8%, to 51.2%
• Limited prevalence data and lack of
representation of Aboriginal people in
epidemiological studies
• Research always suggests a mainstream view of
risk, resilience and aetiology
• No published research into the efficacy of
traditional treatments, mainstream counselling,
therapies or intervention programs with
Aboriginal people
• Predominant “Absence of Evidence” view in
relation to the existence of culture-bound
syndromes

18. The role of IPS in
finding some
solutions…..

19. Solution: Development of Unique Tests &
Assessments
1. The Westerman Aboriginal Symptom
Checklist - Youth (WASC-Y: Westerman,
2003) and WASC-A, resulting in:
• Identify early stage of risk
• Population level data specific to
Aboriginal people on the nature of
suicide
• Valid prevalence data
• Information on co-occurrence of
disorder
• Able to evaluate efficacy of intervention

20. Unique Tests & Assessments
2. Aboriginal Mental Health Cultural Assessment
Models (Westerman, 2003) to enable
diagnostic formulation across major
disorders – spiritual visits or being sung;
sorry cuts; longing for country
3. Acculturative Stress Scale for Aboriginal
Australians (Westerman, 2003)
• Relationship with risk –15% of variance
for psychological symptoms accounted for
by culture stress
• Mental health outcome. The focus is on
reducing culture stress

21. Unique Tests & Assessments
4. The Acculturation Scale for Aboriginal
Australians (Westerman, 2003)
• Provides cultural evidence for disorder – e.g.
command automatism; possession psychosis etc., so
that ethnic or racial heritage is concretised rather
than an amorphous construct (Tseng, Matthews &
Elwyn, 2004; Diamond, 1978)
• Gauges the extent of connection with culture /
beliefs relative to other Aboriginal people
(Westerman, 2003)
• Forces practitioners to explore a cultural basis for
all illness
• Addresses the issue of test bias
• Community then provides collateral information to
support assessment/diagnosis

22. Solution: Workforce and Organisational
Cultural Competencies
• Determined the predictors of cultural
competence via the Aboriginal Mental
Health Cultural Competency Test (CCT:
Westerman, 2003, 2009 in prep)
• Knowledge
• Beliefs and Attitudes
• Skills & Abilities
• Resources and Linkages
• Organisational Cultural Competencies
• Objective, measurable over time and
compared with national norms

23. Workforce and Organisational Cultural
Competencies
Tied in with comprehensive cultural intervention
including:
2. Indigenous Specific Mental Health Training – 24
packages; 8,861 people trained since 2000
3. E-learning
4. Culture-specific Client Policies and Procedures
5. Cultural Review of Programs, Tests and Assessments
6. Cultural Supervision Plans / Mutual Learning
Contracts
7. Development of Indigenous Mental Health Service
Delivery Models in which SP’s need to attain a ‘black
card’ of cultural competence and community then
oversee the ongoing delivery of the program

24. Solution: Culturally Driven and Valid
Research
• Evidence based practice for disorders via population
level data – e.g. of Aboriginal suicide
• Validation of CB syndromes
• Adaptation of Counselling Micro-skills - e.g. self-
disclosures; gratuitous concurrence
• Adapt therapies to incorporate cultural differences
in learning styles – visual memory
• Determine the role of mainstream therapies in
treating CB syndromes e.g. longing for country
• Validation of traditional treatment hierarchy
• Cultural evidence for organisational policies relative
to cultural norms e.g. second/third hand
referrals/cultural vouching for engagement

25. Solution: Developing Community Capacity –
whole of community suicide intervention
programs
• Demand for forums from community
• Unique content
• Three different groups – SP’s, community & youth
• Training for SP’s and psycho-education for youth &
service providers
• Outcome driven evaluations demonstrating
consistently statistically significant increases
focusing on:
• Skills increases
• Knowledge
• Intentions to assist
• High risk regions and potential for risk targeted
• 8 regions since July, 2002 delivered over 3 phases
• Over 1,800 trained – 85% Indigenous

26. Where to from here?
• We need to continue to improve diagnosis,
prognosis and intervention
• Replicate models for use with other
presenting issues
• Transferability across different groups
• Longitudinal data to determine impacts
• Ensure that cultural competency becomes a
minimum standard
• Continue to facilitate community development
of unique programs, models and services which
challenge mainstream constructs of mental
health

27. Contact Details.
Indigenous Psychological Services
PO Box 1198
East Victoria Park
WA 9681
Phone 61 (08) 9362 2036
Fax 61 (08) 9362 5546
Email: ips@ips.iinet.net.au
Website: www.indigenouspsychservices.com.au