Indigenous Mental Indigenous Mental Health in Remote Health in Remote CommunitiesCommunities

Pauline Guerin, PhDPauline Guerin, PhD

School of Nursing & MidwiferySchool of Nursing & Midwifery

Flinders UniversityFlinders University

Projects and TeamProjects and Team

Australian Research Council funding, 2008-2010Australian Research Council funding, 2008-2010 Applying a contextual model of community research and interventionApplying a contextual model of community research and intervention

AIATSIS (Australian Institute of Aboriginal and AIATSIS (Australian Institute of Aboriginal and Torres Strait Islander Studies) Funding, 2008-Torres Strait Islander Studies) Funding, 2008-20102010

Community perspectives on the issues, treatment and service deliveryCommunity perspectives on the issues, treatment and service delivery

Project TeamProject Team– Professor Bernard Guerin, UniSA PsychologyProfessor Bernard Guerin, UniSA Psychology– Dr. Pauline Guerin, Flinders SONMDr. Pauline Guerin, Flinders SONM– Deirdre Tedmanson, UniSA School of Social Work and Deirdre Tedmanson, UniSA School of Social Work and

Social PolicySocial Policy– Yvonne Clark, University of Adelaide Psychology Yvonne Clark, University of Adelaide Psychology

(formerly CAMHS)(formerly CAMHS)

Aims of ProjectAims of Project

to document systematically remote to document systematically remote Indigenous communities’ and service Indigenous communities’ and service providers’ views on:providers’ views on:– mental health and well-being, mental health and well-being, – experiences of the mental health services, experiences of the mental health services, – traditional interventions (where appropriate), traditional interventions (where appropriate),

to obtain more diverse and complex stories to obtain more diverse and complex stories about how factors such as:about how factors such as:

loss of land, loss of land, family and community changes, family and community changes, loss of traditions, loss of traditions, and spirituality and spirituality

– contribute to mental ill health and compromised contribute to mental ill health and compromised well-being. well-being.

Aims cont…Aims cont…

to recommend how communities and to recommend how communities and services might use such information services might use such information while being mindful that such while being mindful that such recommendations need to retain the recommendations need to retain the diversity inherent in the communities, diversity inherent in the communities, and and

to provide guidance for local to provide guidance for local interventions rather than a generic plan interventions rather than a generic plan wrongly assumed to work anywherewrongly assumed to work anywhere

Conceptions of Mental Conceptions of Mental HealthHealth There have been moves away from There have been moves away from

individual, biological approaches to individual, biological approaches to mental health towards social mental health towards social approachesapproaches– Indigenous-specific approachesIndigenous-specific approaches– Transcultural approachesTranscultural approaches– Dealing with specific issues (e.g., petrol Dealing with specific issues (e.g., petrol

sniffing)sniffing)– The role of racism and discrimination in The role of racism and discrimination in

mental health and well-beingmental health and well-being

Indigenous approachesIndigenous approaches

Emphasis on roles of family, land, Emphasis on roles of family, land, traditions, whole-of-life, traditions, whole-of-life, spirituality & community spirituality & community involvementinvolvement– Anderson, 2004; Atkinson, 2002; Anderson, 2004; Atkinson, 2002;

Dudgeon, Garvey & Pickett, 2000; Dudgeon, Garvey & Pickett, 2000; Hunter, 2004; Trudgen, 2000; Vicary Hunter, 2004; Trudgen, 2000; Vicary & Bishop, 2005; Vicary & & Bishop, 2005; Vicary & Westerman, 2004Westerman, 2004

Transcultural Mental Transcultural Mental HealthHealth E.g., refugee mental health, focus on E.g., refugee mental health, focus on

community-based approachescommunity-based approaches– Burr, 2002; Dossa, 2002; Ferguson & Burr, 2002; Dossa, 2002; Ferguson &

Pittaway, 1999; Giosan, Glovsky & Haslam, Pittaway, 1999; Giosan, Glovsky & Haslam, 2001; Guerin, Guerin, Diiriye, & Yates, 2001; Guerin, Guerin, Diiriye, & Yates, 2004; Guerin, Elmi & Guerin, 2006; Hodes, 2004; Guerin, Elmi & Guerin, 2006; Hodes, 2002; Holzinger, Kilian, Lindenback, 2002; Holzinger, Kilian, Lindenback, Petscheleit, & Angermeyer, 2003; Ryan, Petscheleit, & Angermeyer, 2003; Ryan, Elmi, Guerin, & Guerin, 2006; Tew, 2005; Elmi, Guerin, & Guerin, 2006; Tew, 2005; Wagner, Duveen, Themel & Verma, 1999Wagner, Duveen, Themel & Verma, 1999

Specific problem Specific problem interventionsinterventions E.g., petrol sniffing, alcohol, & E.g., petrol sniffing, alcohol, &

violenceviolence– Brady, 2002; Capp, Deane & Brady, 2002; Capp, Deane &

Lambert, 2001; D’Abbs & MacLean, Lambert, 2001; D’Abbs & MacLean, 2000; D’Abbs & Brady, 2004; Day, 2000; D’Abbs & Brady, 2004; Day, Howells & Casey, 2003; Gray, Howells & Casey, 2003; Gray, Pulver, Saggers & Waldon, 2006; Pulver, Saggers & Waldon, 2006; Neilson, 2005; Tedmanson & Maher, Neilson, 2005; Tedmanson & Maher, 20032003

Racism & Racism & DiscriminationDiscrimination Growing international literature Growing international literature

relating to how racism and relating to how racism and discrimination can contribute to discrimination can contribute to mental ill healthmental ill health– Clark, Anderson, Clark & Williams, Clark, Anderson, Clark & Williams,

1999; Jasinskaja-Lahti, Liebkind & 1999; Jasinskaja-Lahti, Liebkind & Perhoniemi, 2006Perhoniemi, 2006

– But methods can be overly But methods can be overly simplified, relying on self-reports/ simplified, relying on self-reports/ perceptions of discrimination/ racism perceptions of discrimination/ racism at bestat best

Remote Indigenous Remote Indigenous Mental HealthMental Health What has this looked like in the What has this looked like in the

literature?literature?– Some individual pathologising, with Some individual pathologising, with

adaptations of Western approachesadaptations of Western approaches Family & community breakdown Family & community breakdown

substance abuse, violence substance abuse, violence individual interventionsindividual interventions

Patel, 2003; Petchokovsky, San Roque, Patel, 2003; Petchokovsky, San Roque, Napaljarri Jurra & Butler 2004; Pollitt, Napaljarri Jurra & Butler 2004; Pollitt, 1997; Sheldon, 20011997; Sheldon, 2001

Social & Political Social & Political PressuresPressures Social and political pressures on Social and political pressures on

communitycommunity community community problems problems community community interventionsinterventions– Brady, 1992; Brown, Sellers, Brown, Brady, 1992; Brown, Sellers, Brown,

& Jackson, 1999; Campbell & & Jackson, 1999; Campbell & Stojanovski, 2001; D’Abbs & Stojanovski, 2001; D’Abbs & MacLean, 2000; Capp, Deane & MacLean, 2000; Capp, Deane & Lambert, 2001Lambert, 2001

Traditional ApproachesTraditional Approaches

Traditional approaches, eg., Traditional approaches, eg., NgangkariNgangkari– Cawte, 1996, Ngaanyatjarra Cawte, 1996, Ngaanyatjarra

Pitjantjatjara Yankunytjatjra Pitjantjatjara Yankunytjatjra Women’s Council Aboriginal Women’s Council Aboriginal Corporation, 2003; Phillips, 2003; Corporation, 2003; Phillips, 2003; Reid, 1983; Ryan, Elmi, Guerin, & Reid, 1983; Ryan, Elmi, Guerin, & Guerin, 2006Guerin, 2006

Questions…Questions…

1.1. Is mental illness in remote Is mental illness in remote communities a problem? Or are communities a problem? Or are these made more salient with these made more salient with media, etc.?media, etc.?

2.2. How are issues viewed or defined How are issues viewed or defined in communities?in communities?

3.3. What does ‘breakdown’ of family What does ‘breakdown’ of family and community mean?and community mean?

Questions, cont.Questions, cont.

4.4. How does ‘loss of land’, ‘breakdown of How does ‘loss of land’, ‘breakdown of family and community’, loss of family and community’, loss of tradition and spirituality actually tradition and spirituality actually contribute to mental ill-health? contribute to mental ill-health?

i.e., what are the causal pathways?i.e., what are the causal pathways?

5.5. How do successful projects actually How do successful projects actually work? work?

i.e., why is it that sometimes what seems i.e., why is it that sometimes what seems a great intervention falls apart when a great intervention falls apart when transplanted into another location?transplanted into another location?

What might we What might we achieve?achieve? Portray a more diverse and Portray a more diverse and

complex glimpse into how ‘mental complex glimpse into how ‘mental health’ and well-being of health’ and well-being of individuals and communities is individuals and communities is viewedviewed

Gain a better idea of the diverse Gain a better idea of the diverse links between the loss of land and links between the loss of land and control, the changes in families and control, the changes in families and communities, and the individual communities, and the individual behaviors that might be classified behaviors that might be classified as “mental health” issuesas “mental health” issues

What might we What might we achieve? cont.achieve? cont. Portray a more diverse and complex Portray a more diverse and complex

glimpse into what can be done by glimpse into what can be done by communities about such problems (if communities about such problems (if they are even seen as problems)they are even seen as problems)

Show how rich contextual data can be Show how rich contextual data can be obtained and documented and obtained and documented and retaining diversityretaining diversity

Show how contextual data can provide Show how contextual data can provide policy and intervention guidancepolicy and intervention guidance

Methods: A ‘community down’ Methods: A ‘community down’ approachapproach

Using principles of Community Using principles of Community Based ResearchBased Research

– Involvement of community in Involvement of community in research processresearch process

May involve ‘capacity’ buildingMay involve ‘capacity’ building

– Partnership, shared responsibility, Partnership, shared responsibility, ownershipownership

– ‘‘Gives back’Gives back’– Action oriented- interventionsAction oriented- interventions

Methods, cont.Methods, cont.

1.1. Informal interviews/ yarns or focus groupsInformal interviews/ yarns or focus groups• Gains current issues, but can risk being ‘dumping Gains current issues, but can risk being ‘dumping

grounds’ for problemsgrounds’ for problems

2.2. Oral historiesOral histories• Can provide deeper, more contextualised accountsCan provide deeper, more contextualised accounts• Influence of time & social context on ‘remembering’Influence of time & social context on ‘remembering’

3.3. ‘‘On the spot’ experience reportsOn the spot’ experience reports• Researchers-in-trainingResearchers-in-training• Benefits- gets at what is happening right now, Benefits- gets at what is happening right now,

without influence of other factorswithout influence of other factors

4.4. Participatory experiencesParticipatory experiences• Over the course of the project and our involvement Over the course of the project and our involvement

in other projects, provides opportunities to see in other projects, provides opportunities to see ourselves what is happening… eg., buying a car in ourselves what is happening… eg., buying a car in AdelaideAdelaide

ThemesThemes

How community members and service How community members and service providers each see the ‘mental health’ providers each see the ‘mental health’ and well-being in remote communitiesand well-being in remote communities

What issues are seen as mental health What issues are seen as mental health issuesissues

How specific “symptoms” or DSM How specific “symptoms” or DSM categories of “mental illness” are categories of “mental illness” are viewed viewed

Traditional treatments, both historic Traditional treatments, both historic and currently practiced, in so far as and currently practiced, in so far as communities are willing to reveal to uscommunities are willing to reveal to us

Themes cont…Themes cont…

Experiences when dealing with Experiences when dealing with mainstream mental health services as mainstream mental health services as clients or carersclients or carers

The diverse links between the loss of land The diverse links between the loss of land and control, the changes in families and and control, the changes in families and communities, discriminatory experiences, communities, discriminatory experiences, and the individual behaviours that might and the individual behaviours that might be classified as “mental health” issuesbe classified as “mental health” issues

What can be done by communities about What can be done by communities about such problems (if they are even seen as such problems (if they are even seen as problems)problems)

Project SitesProject Sites

AIATSISAIATSIS– APY lands, large community and nearby APY lands, large community and nearby

homelandshomelands ARCARC

– APY lands, north Flinders Ranges, & other APY lands, north Flinders Ranges, & other rural site TBArural site TBA

Rationale: selecting only 1 site limits a Rationale: selecting only 1 site limits a broader understanding and anonymity, broader understanding and anonymity, but trying to aim for multiple sites would but trying to aim for multiple sites would limit depth of data and ability to limit depth of data and ability to ‘contextualise’‘contextualise’

Status of ProjectStatus of Project

Currently gaining ethical approval Currently gaining ethical approval (some minor revisions)(some minor revisions)

Other projects (e.g., Desert Other projects (e.g., Desert Knowledge, other ARC funding) Knowledge, other ARC funding) has maintained involvement with has maintained involvement with communitiescommunities

Some ChallengesSome Challenges

DistanceDistance– Challenges the ability to apply CBPR Challenges the ability to apply CBPR

approachesapproaches EthicsEthics

– Committees accustomed to Western scientific Committees accustomed to Western scientific ethics which are not always ‘ethical’ in ethics which are not always ‘ethical’ in ‘community’ contexts, e.g., use of names‘community’ contexts, e.g., use of names

Movements of researchers since initial Movements of researchers since initial developmentdevelopment– Delayed progressDelayed progress

Web links of interestWeb links of interest

AIATSIS: Australian Institute for Aboriginal and Torres AIATSIS: Australian Institute for Aboriginal and Torres Strait Islander StudiesStrait Islander Studies– http://www.aiatsis.gov.au/http://www.aiatsis.gov.au/

ARC: Australian Research CouncilARC: Australian Research Council– http://www.arc.gov.au/http://www.arc.gov.au/

MMHA: Multicultural Mental Health AustraliaMMHA: Multicultural Mental Health Australia– http://www.mmha.org.au/http://www.mmha.org.au/

AUSEINET Australian Network for Promotion,AUSEINET Australian Network for Promotion,Prevention and Early Intervention for Mental Health Prevention and Early Intervention for Mental Health – http://auseinet.com/http://auseinet.com/

Aboriginal Health Research UnitAboriginal Health Research Unit– http://aboriginalhealth.flinders.edu.au/http://aboriginalhealth.flinders.edu.au/

Anangu Lands Paper TrackerAnangu Lands Paper Tracker– www.papertracker.com.auwww.papertracker.com.au

Indigenous Mental Health in Indigenous Mental Health in Remote CommunitiesRemote Communities

Pauline GuerinPauline Guerinpauline.guerin@flinders.edu.aupauline.guerin@flinders.edu.auBernard GuerinBernard GuerinBernard.guerin@unisa.edu.auBernard.guerin@unisa.edu.auDeirdre TedmansonDeirdre TedmansonDeirdre.tedmanson@unisa.edu.auDeirdre.tedmanson@unisa.edu.auYvonne ClarkYvonne ClarkYvonne.clark@adelaide.edu.auYvonne.clark@adelaide.edu.au