Indigenous mental health

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.

1. Data
issues - how
big is the problem?

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.

• 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.

These issues have been identified in many reports and it is time that they
were addressed.

2. Understanding the problem.

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.

3. Treating
the problem - mental health services

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:

• 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.

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:

• 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.

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