Aboriginal and Torres Strait Islander people experience considerably poorer physical and mental health in comparison to the wider Australian community. Research shows that, although there are proportionately more Aboriginal and Torres Strait Islander people than non-Aboriginal and Torres Strait Islander people who refrain from drinking [1646], those who do drink are more likely to do so at high-risk levels [1646, 1647]. Between 2014–2018, both Aboriginal and Torres Strait Islander men and women died from alcohol-related causes at a rate four and a half times higher than their non-Aboriginal and Torres Strait Islander counterparts [1646]. As a result, it is possible that heavy drinking may be normalised within some communities, which may act as a barrier to people seeking treatment [1648].
However, alcohol is not the only substance that presents a major concern for Aboriginal and Torres Strait Islander people. In 2012-13, 46% of Aboriginal and Torres Strait Islander people over the age of 15 years reported using an illicit substance in their lifetime; in 2018-2019, 29% reported use in the previous 12- months (37% of men; 22% of women) [1649]. Substances most commonly used in 2018-19 included cannabis (25%), amphetamines (3%), and non-prescription analgesics (3%). d’Abbs and colleagues [1650, 1651] have also highlighted the devastating effects of volatile substance use and petrol-sniffing among Aboriginal and Torres Strait Islander communities in Central Australia. Of concern, in 2019 the rate of unintentional drug-related deaths (involving non-pharmaceutical opioids, stimulants, pharmaceutical opioids, benzodiazepines, and cannabinoids) was three times higher among Aboriginal and Torres Strait Islander (20 per 100,000 people) than non-Aboriginal and Torres Strait Islander (6 per 100,000 people) people [1652]. Research has also found that Aboriginal and Torres Strait Islander people aged over 18 years are three times as likely to be current daily cigarette smokers (43%) as non-Aboriginal and Torres Strait Islander people (14%) [1653].
Aboriginal and Torres Strait Islander people are also over-represented in inpatient mental health services, with almost twice as many Aboriginal and Torres Strait Islander people than non-Aboriginal and Torres Strait Islander people hospitalised for a mental illness between 2015–2017 [1654]. Across Australia, the most common mental health conditions requiring hospitalisation between 2015-2017 were substance-induced mental and behavioural disorders (40%), schizophrenia spectrum and other psychotic disorders (23%), depressive and bipolar disorders (13%), and anxiety disorders (12%) [1655]. Further, in 2018–19, Aboriginal and Torres Strait Islander people were almost three times more likely than non-Aboriginal and Torres Strait Islander people to report high or very high levels of psychological distress [1646, 1656].
In 2014–2018, the suicide rate for Aboriginal and Torres Strait Islander people across all age groups was almost double the non-Aboriginal and Torres Strait Islander rate, and highest among those aged 35-39 years [1646]. These rates are likely to underestimate actual suicide prevalence, as self-harm, suicidal ideation, and suicidal attempts are under-reported among Aboriginal and Torres Strait Islander people [1657]. Aboriginal and Torres Strait Islander people were also hospitalised for self-harm at nearly three times the rate of non-Aboriginal and Torres Strait Islander people [1646].
There is limited data regarding the population prevalence of AOD and mental health disorders, or their co-occurrence, among Aboriginal and Torres Strait Islander communities; however, a landmark study examining the prevalence of mental health and AOD use disorders among 544 Aboriginal and Torres Strait Islander adults located in urban, regional and remote areas of Southern Queensland and two Aboriginal Reserves located in New South Wales was conducted between 2014-2016 [1658]. This study found that 67% of the sample had experienced a mood, anxiety, or AOD use disorder in their lifetime (73% of men and 63% of women); a rate 30% higher than that observed in the Australian general population. Among those who met diagnostic criteria for an AOD use disorder in the past 12-months, 28% of men and 71% of women also met criteria for a co-occurring mood or anxiety disorder. Table 59 presents the crude prevalence estimates for each mental disorder.
Table 59: Crude prevalence of lifetime mental health disorders among Aboriginal and Torres Strait Islander people
| |
Men % |
Women % |
Total % |
| Mood disorders |
| Major depressive disorder |
18.4 |
27.3 |
23.9 |
| Dysthymic disorder |
2.4 |
3.6 |
3.1 |
| Bipolar disorders |
0.9 |
3.3 |
2.4 |
| Any mood disorder |
31.9 |
38.9 |
36.2 |
| Anxiety disorders |
| Panic disorder |
7.2 |
15.1 |
12.1 |
| Social phobia |
9.7 |
12.2 |
11.2 |
| Specific phobia |
9.7 |
13.6 |
12.1 |
| Generalised anxiety disorder |
5.7 |
6.2 |
6.1 |
| Post-traumatic stress disorder |
13.5 |
25.2 |
20.8 |
| Obsessive-compulsive disorder |
2.4 |
3.3 |
2.9 |
| Any anxiety disorder |
32.9 |
49.0 |
42.8 |
| Substance use disorders |
| Alcohol abuse |
25.6 |
15.4 |
19.3 |
| Alcohol dependence |
28.5 |
19.6 |
22.9 |
| Substance abuse |
15.9 |
4.2 |
8.6 |
| Substance dependence |
16.4 |
8.0 |
11.2 |
| Any substance use disorder |
54.6 |
33.5 |
41.5 |
| Any mental disorder |
72.9 |
63.2 |
66.9 |
|
Source: Nasir et al. [1658].
There is also little research regarding the prevalence of mental health conditions among Aboriginal and Torres Strait Islander people engaged in AOD treatment; however, analysis of data from a remote Aboriginal residential rehabilitation service in Western NSW revealed that 51% of clients had been diagnosed with a mental health condition [1659]. A subsequent study conducted across other Aboriginal and Torres Strait Islander residential rehabilitation services found that 78% of clients experienced moderate to very high psychological distress, and 88% were categorised as being at risk of a mental health condition [1660]. Other studies have also shown an association between depression, anxiety, suicide, and alcohol dependence in Aboriginal and Torres Strait Islander communities [1661–1663], and an association between the frequency of alcohol consumption and the experiencing of hallucinations, paranoia, self-harm, and panic [1664–1666].
Moreover, as with the general population, Aboriginal and Torres Strait Islander people who experience co-occurring disorders are more likely to experience a range of other difficulties than those with a mental health or AOD use disorder alone [1667]. Aboriginal and Torres Strait Islander women accessing treatment for co-occurring mental health and AOD use disorders have reported that their co-occurring conditions had led to severe and wide-ranging negative outcomes, such as general poor health, diminished social networks, unemployment, and financial instability. These women also reported that their co-occurring conditions had a serious negative impact on their ability to care for themselves and others (e.g., with some women reporting children being removed from their care) [1668]. Factors that contribute to elevated rates of AOD use disorders and psychiatric morbidity in Aboriginal and Torres Strait Islander communities include the long-term effects of intergenerational trauma linked to the stolen generations and assimilation policies of the Australian Government; high rates of exposure to other traumas; the destruction of social infrastructure; rapid urbanisation and poverty; cultural, spiritual and emotional alienation; loss of identity; family dislocation; and increased AOD consumption [1669–1672]. Trauma exposure, co-occurring PTSD and AOD problems are disproportionately high among Aboriginal and Torres Strait Islander people [1668, 1673]. In a sample of people from remote Aboriginal and Torres Strait Islander communities in Western Australia, 96% reported a history of trauma exposure, 55% met diagnostic criteria for PTSD, and, of these, 91% also met diagnostic criteria for an alcohol use disorder [1673]. Aboriginal and Torres Strait Islander women accessing treatment services have reported a perceived association between negative early life events (e.g., domestic violence, physical and sexual abuse) and the onset of their AOD and mental health conditions, as well as their ability to trust and share personal information with others, including health providers [1668, 1674]. These difficulties may be a significant barrier to help-seeking.
The need for culturally appropriate tools for identifying co-occurring conditions (such as the IRIS, described in Chapter B3), as well as culturally appropriate integrated services that are linked with Aboriginal and Torres Strait Islander services and consultants is well recognised [1675, 1676]. Although integrated treatment is recommended, research examining the efficacy of integrated treatments for co-occurring AOD and mental health conditions among Aboriginal and Torres Strait Islander clients is limited. However, findings from preliminary research suggest that culturally adapted brief interventions may improve both wellbeing and substance dependence. In collaboration with Aboriginal medical health workers from three remote communities in the Northern Territory, Nagel and colleagues [1677] developed a brief intervention consisting of two one-hour treatment sessions delivered two to six weeks apart, which integrated problem-solving, motivational therapy, and self-management principles. Compared to treatment as usual, those randomised to the brief intervention demonstrated greater and sustained improvements in both mental health and alcohol dependence, and a trend toward greater improvements in cannabis dependence.
Existing mainstream models of practice in the AOD field have overwhelmingly been developed within Western systems of knowledge. As a result, they are not necessarily generalisable to other cultures and may ignore important Aboriginal and Torres Strait Islander perspectives and needs. Workers should also be aware of the cultural diversity within Aboriginal and Torres Strait Islander populations, which is often overlooked [1678, 1679]. Differences in cultural identity extend to different languages, accessing traditional lands, practising traditional culture, laws and governance, as well as family and kinship structures [1679, 1680]. Recognising and responding to the complexities of Aboriginal and Torres Strait Islander identity involves acknowledging the significance of diverse language and family groups, as well as the differences in gender relationships, all of which can involve complex relationships which determine the level of interaction between family and kin [1681]. The different forms of distress experienced by Aboriginal and Torres Strait Islander people, as well as the different pathways to recovery, need to be identified, which depend on a diverse range of beliefs and experiences [1682]. It is therefore important that AOD workers try to familiarise themselves with more specific information regarding the Aboriginal and Torres Strait Islander peoples in their community. These and other issues to be aware of when working with Aboriginal and Torres Strait Islander clients are summarised in Table 60.
Recommendations for the provision of culturally appropriate services are provided in Table 61. Further detail and resources that may assist AOD workers and services in providing culturally appropriate care can be found in the Network of Alcohol and other Drugs Agencies AOD treatment guidelines for working with Aboriginal and Torres Strait Islander People in non-Indigenous settings [1675]. These Guidelines include Yarning about Mental Health training, which was also developed by the Australian Integrated Mental Health Initiative to strengthen AOD workforce knowledge and skills in mental health approaches, including culturally adapted strategies and tools for understanding mental health, promoting wellbeing, and delivering brief interventions. An evaluation of the training found that trainees perceived the program to be highly appropriate and helpful in their work with Aboriginal and Torres Strait Islander AOD clients, as well as significant improvement in confidence and knowledge related to Aboriginal and Torres Strait Islander mental health and wellbeing [1683].
Table 60: Considerations for AOD workers in working with Aboriginal and Torres Strait Islander clients
- The concept of family (including extended family and relatives) and community in Aboriginal and Torres Strait Islander culture is very important and includes immediate and extended relations. With the permission of the client, family members should be included in therapy as much as possible, and the client should be treated within the context of their community. Families are a strength that can be drawn upon to complement mental health and AOD treatment [1668]. Community and Aboriginal and Torres Strait Islander support groups may also be useful services.
|
- Many Aboriginal and Torres Strait Islander people have a holistic concept of health, which is often referred to as social and emotional wellbeing [1657]. This multifaceted concept reflects the Aboriginal and Torres Strait Islander cultural concept of health, which includes physical, psychological, social, cultural, and spiritual health and the importance of connections to land, culture, family, spirituality, ancestry, and community. These connections are maintained through generations and contribute to a person’s wellbeing. As such, incorporation of these factors is essential during treatment. Integrated or coordinated services are therefore particularly important for addressing AOD and mental health conditions [108, 1668, 1684]. Nasir et al. [1658] point to the importance of land and culture as a possible explanation for lower rates of AOD and mental health disorders among Aboriginal and Torres Strait Islander people living in Reserve and remote areas relative to those living in other settings. Men accessing AOD services have also reported that they perceive traditional arts and crafts, culturally-focused talks, and connecting with the land to be the most beneficial cultural activities [1685].
|
- There are high rates of trauma, grief, and loss in Aboriginal and Torres Strait Islander communities as Aboriginal and Torres Strait Islander people are faced with death and serious illness within their extended family more often than non-Aboriginal and Torres Strait Islander people, and at a younger age. There are also issues of unresolved grief, continued cultural loss and intergenerational trauma regarding the European colonisation and mistreatment since then (e.g., stolen generations). Approaches should address underlying issues of repeated trauma, stress, and grief [1686].
|
- Stigma and victimisation continue to exist today and are likely to impact on mental health and AOD use.
|
- Issues of domestic violence, poverty, and family AOD use are also likely to play a key role.
|
- When working with Aboriginal and Torres Strait Islander clients with apparent psychotic symptoms, it is important to clarify the cultural appropriateness of such symptoms. For example, it is not uncommon for some Aboriginal and Torres Strait Islander people to hear recently departed relatives and see spirits representing ancestors. This kind of spiritual experience is culturally valid and therefore is not a symptom of psychosis.
|
- Workers should be aware of the impact of intensely distressing levels of shame that many Aboriginal and Torres Strait Islander clients experience. This shame can be exacerbated when dealing with a non-Aboriginal worker. Involving an experienced Aboriginal worker in the client’s care can help achieve the best outcomes.
|
- Use appropriate language (e.g., avoid jargon, or technical or medical terminology, use culturally appropriate terms to describe AOD) and include appropriate written materials to reinforce key verbal messages.
|
- Consider that you may be viewed as a member of a culture that has caused damage to Aboriginal and Torres Strait Islander culture. Anticipate and prepare a plan to deal with issues of anger, resentment and/or suspicion. Engagement is likely to require increased attention.
|
- Enclosed spaces may increase anxiety in Aboriginal and Torres Strait Islander clients.
|
- Direct questioning can be perceived as being threatening and intrusive and therefore should be kept to a minimum. A method of three-way talking may often be helpful, in which a client uses a third person (such as a family member) as a mediator to exchange information with the service provider.
|
- Watch the client’s body language and mirror it if possible. For instance, direct eye contact is often viewed as impolite in Aboriginal and Torres Strait Islander communities and is often avoided. Speaking softly with brief answers may be a sign of shyness or good manners.
|
- Be respectful of cultural prohibitions such as:
- Referring to a deceased person by name.
- Referring to certain close relatives by name (e.g., a Torres Strait Islander male may not refer to his brother-in-law by name).
- Appearing to criticise elders or family members.
- Confiding personal information to a member of the opposite sex – men’s and women’s business are usually kept separate (this may require a same sex AOD worker).
|
- Consultation may take longer so set aside extra time.
|
- Be aware that levels of literacy may be low.
|
- It is important to be clear about your role and the types of things you would like to cover in the consultation.
|
- Assessment of Aboriginal and Torres Strait Islander clients should occur within their own cultural context.
|
- Act as an advocate for the client where necessary in guiding them through the health care system.
|
- Understand that developing relationships with clients and communities will take time and that establishing these relationships is often necessary prior to engaging in treatment and learning more about how to appropriately interact with clients.
|
- Be proactive in engaging with the local community rather than waiting for them to access AOD or mental health services.
|
Source: [234, 776, 1686–1695].
Table 61: Considerations for AOD services providing support to Aboriginal and Torres Strait Islander clients
- Create a welcoming environment, including demonstrating cultural respect.
|
- Provide flexible service delivery, with consistent and reliable staff members with whom people can build trust and rapport. Consider cultural differences in service delivery, such as using cultural mapping to understand family and community dynamics.
|
- Include Aboriginal and Torres Strait Islander voices in AOD services by consulting and engaging relevant communities. Establish a consultation protocol and communicate regularly to Aboriginal and Torres Strait Islander communities about the work you are doing.
|
- Collaborate with Aboriginal and Torres Strait Islander organisations and workers to identify and address service gaps.
|
- Provide opportunities to staff to improve knowledge of Aboriginal and Torres Strait Islander issues, culture, and history, including specific training in gender roles, communication, and trauma.
|
- Make efforts to recruit and retain Aboriginal and Torres Strait Islander workers within your organisation.
|
- Better integration of mental health and AOD services, and greater collaboration between these services and other organisations (e.g., housing, education) [108].
|
- Greater promotion of available services (e.g., active presence of mental health/AOD workers at local community events).
|
- Provide information and group family support for families and carers of people with co-occurring AOD and mental health conditions.
|
- Support groups to be run at local services to allow clients to share experiences with others in similar situations and to reduce isolation [1696].
|
- More childcare options available for clients seeking help from inpatient services.
|
- Greater use of outreach services in remote areas as a means of simplifying access to relevant services (e.g., rehabilitation, mental health, withdrawal management) and creating a less ‘medicalised’ environment.
|
- Services better addressing factors that make it difficult for people to get appointments (e.g., inflexible appointment times, unreliable transportation to services).
|
Source: Network of Alcohol and other Drugs Agencies [1675]; Lee et al. [1668]; and Liu et al. [108].