Indigenous mental health
Speech by Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner, Human Rights and Equal Opportunity Commission
Djirruwang Aboriginal Health Program, Charles Sturt University - Student Conference, 29 September 2005
I would like to begin by acknowledging the traditional owners of the land on which we meet - the Waradjuri nation and the elders present. I also acknowledge our hosts - the Dijrruwang Program at Charles Sturt University , and thank you for inviting me here to address this Gathering.
I welcome Gatherings such as this one because it shines light on the issue of Aboriginal and Torres Strait Islander mental ill health; an issue that is overlooked in the debate about passive welfare and substance abuse and dealt with inappropriately through the criminal justice system. Yet, without addressing mental ill-health as an issue in its own right, efforts to improve life in many Indigenous communities, in both urban and remote, are likely to come undone. Poor mental health contributes to the crisis of family violence, anti-social behaviour, substance misuse, confrontation with the legal system, low participation in schooling and employment that is evident in a significant number of Aboriginal and Torres Strait Islander communities.
Reflecting on the invisibility of this issue, I note that this year it was only through my intervention that the Senate Select Committee on Mental Health expanded its proposed terms of reference to include Aboriginal and Torres Strait Islander mental health issues and services as a topic of consideration. Along with the Human Rights Commissioner and Acting Disability Discrimination Commissioner, I made a submission to the Committee raising many of the issues I will discuss here. The Committee is due to report in March 2006.
The Human Rights and Equal Opportunity Commission has been actively involved in addressing the mental health of Indigenous peoples. I highlight:
- In 1993, the landmark Report of the National Inquiry into the Human Rights of People with Mental Illness , known as the Burdekin report. This helped to highlight the issues confronting Indigenous people with a mental illness including many of the issues I will raise today. Many of the findings are still current 12 years later.
- In 1997, the well known Bringing them home report also highlighted mental health issues, particularly in relation to Aboriginal people forcibly and unnecessarily removed from their families as children.
In the Social Justice Report 2004, I signalled I would continue this focus by addressing the mental health concerns of Aboriginal and Torres Strait Islander peoples as a priority throughout my term as Commissioner.
To that end, in September 2004 I took part in a mental health community forum held in Darwin hosted by the Human Rights Commissioner and Acting Disability Discrimination Commissioner, Dr Sev Ozdowski, and the Mental Health Council of Australia. In this consultation, I heard first hand of the experiences of Aboriginal mental health service consumers, providers and their families and carers. This was complemented by discussions with Dr Ozdowski who shared the findings of his national consultations and I must say, the issues were consistently common. A report on the consultations has been prepared but it is currently under embargo so I am prevented from quoting from it directly here. However, it is due for public release by the end of the year and I commend it to you. While it is not Indigenous-specific, it does recount the experiences of Indigenous mental health consumers and discusses the failure of Australia ' s mental health system to provide adequate care to Aboriginal and Torres Strait Islander communities, as well as the broader community.
The three main issues I want to discuss today are:
- Data issues;
- The need for greater understanding of Aboriginal and Torres Strait Islander mental health and ill-health; and
- Mental health services for Aboriginal and Torres Strait Islander people.
- Data issues - how big is the problem?
- First, there is an incomplete identification of Indigenous people in census data (i.e. people not identifying) as well as in administrative data (i.e. hospital records).
- Second, it is difficult to collect data from remote communities, and
- Third, primary health care providers such as Aboriginal health workers and drug and alcohol workers do not have a uniform process whereby to collect data.
- Understanding the problem.
- Treating the problem - mental health services
- 74% of residents of discrete communities have inadequate access to visiting or resident mental health workers;
- Aboriginal and Torres Strait Islander people have disproportionately low access to general practitioners and private medical specialists, such as psychiatrists, because of the cost of such services.
- only 38% of Commonwealth funded Aboriginal Community Controlled Health Services have a dedicated mental health or social and emotional well being worker.
- increasing resources to Aboriginal Community Controlled Health Services to meet the increasing mental health and social and emotional well being needs placed upon the Aboriginal and Torres Strait Islander primary health care sector. These services are also best placed as providers of traditional mental health healing and other ways of addressing mental ill-health. Linking into health services activities, CDEP and SRAs could also be used as vehicles of mental health promotion within communities.
- reforming mainstream and private provider community based mental health care to better meet the needs of Aboriginal and Torres Strait Islander consumers. This could be through cultural awareness training of staff working in these agencies.
- training an Indigenous mental health workforce - psychiatrists, psychologists and so on - as happens here and can I take this opportunity to praise the work done at the Dijrruwang Program to address Indigenous mental health needs - its value cannot be overestimated.
No one is really sure how big an issue mental ill-health is in communities, although anecdotal evidence and smaller studies suggests it is a significant problem.
The most significant data yet obtained has been through the emotional and social well-being component of the Western Australian Aboriginal Child Health Survey published in April 2005, with a survey sample of approximately 5,000 children. It reported that 1 in 4 Aboriginal children are at high risk of developing clinically significant emotional or behavioural difficulties. This compares to about 1 in 6-7 of non-Indigenous children.
Most of the data we have about mental ill-health in Aboriginal and Torres Strait Islander adults is that gleaned after crisis situations, that is, when the mental health issue results in hospitalisation. According to the Australian Bureau of Statistics and the Australian Institute of Health and Welfare, in 2003 - 2004 Aboriginal and Torres Strait Islander males were hospitalised at 3 times the rate of non-Indigenous males for a variety of mental disorders; while for females the rate was twice that of non-Indigenous females. While such data is useful, it is of limited use in quantifying the burden of mental ill-health in communities.
There is currently no national data collection process that is able to provide accurate information on the incidence of mental health disorders or treatment occurring among Aboriginal and Torres Strait Islanders in communities. All we know is that suicide, substance abuse and family and community violence are problems and there are services in place in some communities to address these, but how matched the response is to the problem it is impossible to determine.
There are many reasons as to why obtaining accurate detailed information is difficult.
These issues have been identified in many reports and it is time that they were addressed.
Understanding the causes of mental ill-health among Aboriginal and Torres Strait Islander peoples is the key to prevention. As the old adage goes: 'prevention is better than cure'. However, few studies have been undertaken to model Aboriginal and Torres Strait Islander mental health or what determines ill-health. The only common conclusion among commentators seems to be that non-Indigenous models of mental health and ill-health have only limited application for Indigenous peoples.
In that regard, listening to Aboriginal and Torres Strait Islander people about mental health is vital. When they are asked, a common theme that emerges is that mental and physical health cannot be treated as discrete issues but must be considered in a holistic context - as the National Aboriginal Health Strategy puts it:
Health to Aboriginal peoples is a matter of determining all aspects of their life, including control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity.
In linking mental and physical health with self determination, the National Aboriginal Health Strategy was ahead of its time. Since then it has become widely accepted that the stress caused by perceived lack of control of one's environment operates as a physical and mental health determinant in all population groups. It is referred to as a 'psychosocial' stress because it involves the interaction of the 'objective' social environment and the 'subjective' perceptions a person might have about it.
However, how this mental health principle manifests in different ways in Aboriginal and Torres Strait Islander peoples is not understood. Studies of Afro-Americans in the United States have linked the experience of racism to a perceived lack of control and poorer mental health 1, and it has been suggested that the perception of control may have a collective dimension in the health and mental health of minority groups 2, not least of all by Indigenous peoples themselves 3. However, how this applies to Aboriginal and Torres Strait Islander peoples is not clear. Other factors may also contribute; for example, some Aboriginal and Torres Strait Islander people have linked their mental health to the land and contact with the land.
Understanding the role self-determination and empowerment can play in Aboriginal and Torres Strait Islander mental health and ill-health has many levels.
For example, at the individual level, ensuring Aboriginal and Torres Strait Islander peoples can access education and employment could be seen as a mental health measure - study after study has shown that an increased perception of control comes with increased income and understanding of one's environment.
At a community level, community-controlled services and self-governance might also be considered as mental health measures.
More broadly, constitutionally protecting the right of self-determination of Aboriginal and Torres Strait Islander peoples at the national level, and other so called 'symbolic' reconciliation measures - such as a treaty - may also need re-thinking in terms of their impact on mental health. In that regard, I also note that the landmark Ways Forward report into Aboriginal and Torres Strait Islander mental health in 1996 linked the mental health of Aboriginal and Torres Strait Islander peoples with the recognition of their rights.
There is a need for greater research into Aboriginal and Torres Strait Islander mental health - research that is carried out in a manner acceptable to Aboriginal and Torres Strait Islander peoples. Only if Aboriginal and Torres Strait Islander mental health is understood can we begin the task of preventing rather than curing the incidence of mental ill-health we see in Aboriginal and Torres Strait Islander peoples today.
There are many points that could be made in relation to the provision of mental health services to Aboriginal and Torres Strait Islander peoples and communities. I refer you to both the upcoming release of the report of the Senate Select Committee on Mental Health and the report of Dr Sev Ozdowski, and the Mental Health Council of Australia for a detailed consideration of these. However, I would identify the following five points as essential:
First , more mental health services are needed in communities. Data presented in the Consultation Paper for the Development of the National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and Emotional Well Being 2004-2009 revealed the lack of availability and accessibility of mental health services to Aboriginal and Torres Strait Islander people:
Primary mental health services are intended to be provided through the rolling out of comprehensive primary health care services through the Primary Health Care Access Program and as set out in the National Strategic Framework for Aboriginal and Torres Strait Islander Health 4. However, the provision of services must be formally linked to need.
Second, ensuring that mental health services are culturally sensitive; to this end, governments need to deal directly with Aboriginal and Torres Strait Islander peoples and communities as well as collaborate with primary health care providers in order to develop and deliver culturally appropriate services. Other avenues to that end include:
Third , breaking down 'health silos'; for example, all medical and para-professionals working with Aboriginal and Torres Strait Islander peoples should have a basic knowledge of possible mental health issues so to facilitate the prevention or early address of mental health problems before they become a crisis. Other silos that must be broken down are those that separate out mental health, family violence and substance abuse services. These should be integrated within comprehensive primary health care services to reflect the fact that these issues are often linked.
Fourth: Programs must be put in place to address the needs of Indigenous carers of the long-term mentally ill living in the community.
Fifth : education of the broader community and Aboriginal and Torres Strait Islander communities about mental health issues. The stigma about mental ill-health must be broken down and communities affected by mental health issues should be informed so they can be as actively involved as possible in relation to addressing mental health issues. Community members who act as carers too need support from other community members as well as from special programs.
The challenges of mental health in Indigenous societies is complex and unfortunately on the increase. Your role on graduation will be a critical intervention and over time I hope that we will be in contact to share your experiences and help influence future interventions. I wish you all the best and thank you for the invitation to speak today.
Thank you
ENDNOTES
1 A 2003 review identified 53 studies that explored racism as a health determinant, almost all in the United States . 24 of these were published in the period 2000-03. The review noted an association between a decline in mental health status and an increase in reported racism. Likewise well-being, life satisfaction, self-esteem and perception of control over life all declined as racism increased. Three out of four studies that looked at major depressive episodes in Afro-Americans found clear links between these and racial discrimination. (Williams R, Neighbours H, Jackson J, Racial/Ethnic Discrimination and Health: Findings from Community Studies, American Jounal of Public Health, Feb 2003, Vol 93, No 2)
2 Mann J, Gostin L, Gruskin S, ( et al ) 'Health and Human Rights', Health and Human Rights: An international journal Vol 1, No 1, Fall 1994 http://www.hsph.harvard.edu/fxbcenter/V1N1.htm (Accessed 5 May 2003.)
3 The Geneva Declaration on the Health and Survival of Indigenous People (1999) issued after an international consultation on the health of Indigenous peoples, organised by the World Health Organization declared Indigenous health to be a 'collective and individual inter-generational continuum encompassing a holistic perspective' Geneva Declaration on the Health and Survival of Indigenous People (1999), World Health Organization consultation on indigenous health, Geneva, 23-26 November 1999 , Part II: http://www.healthsite.co.nz/hauora_maori/resources/feature/0001/002.htm
4 Within the National Strategic Framework for Aboriginal and Torres Strait Islander Health, Key Result Areas 1 -3 set out that the delivery of 'comprehensive primary health care' to communities as a main plank of the strategy: this includes nutritionists, infant care services, health promotion services, and mental health services . The Primary Health Care Access Program intersects with the National Strategic Framework at this point - this is the program that will deliver the services according to the Framework. Ideally Aboriginal Community Controlled Health Services will deliver comprehensive primary health care .
Last updated 05 October 2005
