THE POLITICAL IS THE CLINICAL

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

THE POLITICAL THE POLITICAL ISIS THE THE CLINICALCLINICAL

Comfort zones, cultural safety and Indigenous ‘mental’ health

MURU MARRI INDIGENOUS HEALTH UNIT

In SummaryIn Summary

MH services fail blackfellas in multiple ways

Re-conceptualising MH as well-being is likely to enhance outcomes, but mandates organisational change

In SummaryIn Summary

International indigenous experience offers

clues, but there are crucial elements unique

to the Australian situation

Change involves a suite of personal and

political challenges, de-‘Othering’ and

culturally safe practice

Indigenous Health StatusIndigenous Health Status

Worst of any group in Australia Median age death (males) 51 yrs

- 26 yrs < non-Indigenous Life expectancy ↓ Maori, Aboriginal

Canadian, Native American Many conditions preventable

Mental Health StatusMental Health Status

NSW figures: self-reported ‘mental

distress’ almost 2 x non-Indig. rate Specific diagnoses: depression, anxiety, bi-

polar disorder, complex PTSD, borderline

personality disorder, A&OD misuse,

cannabis/amphetamine psychosis, but …

Focus on ‘Mental’ Health / IllnessFocus on ‘Mental’ Health / Illness

History of incorrect diagnosis History of medical complicity in eugenics

movement, ‘locked’ hospitals, child

removal and separatist political schemes Negative, ‘deficit’ approach – ignores

social, historical and cultural aspects,

including resilience

ThenThen

NowNow

I’m not ‘mental’I’m not ‘mental’

Narrow approach: no longer acceptable Stigma Lack of fit with Koori understandings Ignores on-going loss and contemporary

consequences of trans-generational trauma Ignores the crucial contribution of

exogenous, early psychic trauma

I’m not ‘mental’I’m not ‘mental’

Psychobiology / Body memory of trauma

– Bessel van der Kolk Psychoneurobiology / Developing brain &

trauma – Bruce Perry, Alan Schore Intergenerational Trauma – Yael Danieli Critical Psychology – Erika Apfelbaum Critiques of Bio-Psychiatry – Peter Breggin

Indigenous PerspectiveIndigenous Perspective

Blackfellas say fundamental connection between colonization and ‘mental distress’

Holistic approach: mental health inseparable from overall health Preferred term is social, spiritual and emotional well-being

Positive ApproachesPositive Approaches

Jettison ‘Deficit’ Model, i.e. that:

Inherited factors explain most Indigenous Australian mental distress

The rest is sheer bloody-mindedness: ‘blacks behaving badly’

Positive ApproachesPositive Approaches

Attend to the social determinants of health: the role of history, politics, geography, culture and socio-economic status

Incorporate recognition of culture and the contexts of people’s lives into treatment/prevention

Towards an integrated modelTowards an integrated model

CulturalSafety

Cultural Awareness

Cultural Competence

Indigenous / CALDB well-being Indigenous / CALDB well-being

Common aspects to working across Indigenous and CALDB populations?

Yes

Same thing?

No: unique aspects of Aboriginal and Torres Strait Islander situation

‘‘First Nations’ First Nations’ StatusStatus

Aboriginal and Torres Strait Islander Australians occupy a unique position as the original inhabitants of Australia

Sovereignty has never been ceded or attenuated by treaty

Indigenous Health StatusIndigenous Health Status

Effects of 200 years of colonization on health

Dispossession – land, language, culture, economic base → grief and loss

‘Stolen Generations’ Trans-Generational Trauma Multi-Generational Chronic Stress Racism, discrimination and ‘virtual’ apartheid

Colonization to healingColonization to healing

Clue from NZ MH competency framework ~ Specific reference to healing for Maori

Similar calls in Australia, but not mandatory - little recognition of:

~ Effects of colonization on health ~ Relationship of ATSI to land / spirituality ~ Sovereignty issue

Big pictureBig picture: treaty and health : treaty and health

Big pictureBig picture: culture and health: culture and health

Connection to culture, language, land

‘protective’ of well-being (Aust./NZ, Jane

McKendrick) Notion of ‘Cultural Resilience’ (US, Iris

HeavyRunner and Kathy Marshall)

Big pictureBig picture: culture and health: culture and health

Big pictureBig picture: Cultural Presence: Cultural Presence

Cultural Safety / Cultural Security affected by relative presence or relative absence of Indigenous culture in the life of the nation

Big pictureBig picture: Minoritisation: Minoritisation

Bruce Perry: psychologically fraught to leave the living culture of the reservation / whanau / Aboriginal community to become a ‘minority’ individual in a western cultural framework

Minoritisation = a reduction in regard

Big pictureBig picture: Minoritisation: Minoritisation

Does such ‘minoritisation’ multiply the

effects of marginalisation?

When you’re already culturally absent /

beyond the pale, does that make it even

easier to become diminished or infantilised

as a person?

Clinical picture: better praxisClinical picture: better praxis

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

* Paul Carter

Clinical picture: better praxisClinical picture: better praxis

Resonance with Cultural Safety

Precept of health professional self-

reflection / examination of own

cultural system

De-Othering Indigenous AustraliaDe-Othering Indigenous Australia

Acceptance of alterity, small ‘o’ otherness

Cultural Imbrication / Cultural Interaction

Up-close-and-personal involvement

Everyday enmeshment, rather than policy fiat

Accepting small ‘o’ othernessAccepting small ‘o’ otherness

Extending our praxisExtending our praxis

To improve Indigenous social, spiritual and emotional well-being it’s time to:

Move beyond DSM IV Move beyond diagnose / treat Go further than the client / professional

dyad

Extending the modelExtending the model

CulturalSafety

Cultural Awareness

Cultural Competence

Cultural Imbrication

The political The political isis the clinical the clinical

Aboriginal and Torres Strait Islander emotional well-being a complex endeavour

Need for positive approaches, a taking account of social determinants and grappling with unfamiliar imperatives: cultural competence / cultural safety / cultural imbrication

But … all this impliesBut … all this implies

Personal challenge to existing comfort zone Professional challenge

# To models of professional distance and

non- disclosure

# Mandates organisational change

But … all this impliesBut … all this implies

Political Challenge

# Implications for training: systems/funding

# Implications for competency standards

# Implied need for increased practitioner

advocacy

‘‘Not For Service’ Rpt. Calls ForNot For Service’ Rpt. Calls For

Funding: increase MH to 12 per cent of total health care funding

Policy: monitoring extent of MH problems PLUS A&OD integration with the National MH Strategy

Leadership and governance: federal Minister PLUS true collaboration between all stakeholders

‘‘Not For Service’ Rpt. Calls ForNot For Service’ Rpt. Calls For

Legal and Human Rights: nationally consistent guidelines on the provision

of MH care Workforce: urgently address the declining

morale and chronic skills shortages in the MH workforce

Accountability: annual reporting mechanism on key indicators, including

10-year targets

The political The political isis the clinical the clinical

Re-emerging role for public intellectual

in conservative times Australian Govt. denial of contemporary

consequences of past practices leads to

inequitable, ineffective policy Time to re-conceive role of health

professional as public professional

The political The political isis the clinical the clinical

Governmental and organizational denial can be as unshakeable as alcoholic denial

Confrontation with evidence-base for fresh approaches to Indigenous well-being a necessary, but not sufficient condition

The political The political isis the clinical the clinical

Clinical duty of care mandates a ‘political’ set of activities to circumvent denial

Could be pursued through changes to the parameters, language and tone of the debate

Requires practitioner involvement in creation of a parallel discourse

The political The political isis the clinical the clinical

Time for Boldness Insist government policy founded-on contemporary effects of loss and TGT Insist initiatives be funded according to need, are sustainable Insist anything else violates professional duty of care