Indigenous Australians

The standards of physical and mental health among Indigenous Australians are poor in comparison with the wider Australian community. Research shows that although there are proportionately more Indigenous people than non-Indigenous people who refrain from drinking [1030], those who do drink are more likely to do so at high-risk levels [1030, 1031]. Between 2008–2012, Indigenous men died from alcohol-related causes at a rate four and a half times higher than their non-Indigenous counterparts, while this rate was six times higher for Indigenous women [1032]. As a result, it is possible that heavy drinking may be normalised within some communities and this could act as a barrier to people seeking treatment [1033].

However, alcohol is not the only substance that presents a major concern for Indigenous people. In 2008, 23% of Indigenous Australians over the age of 15 years reported using an illicit substance in the previous 12-months, and 43% reported lifetime use [1030]. Substances most commonly used included cannabis (17%), non-prescription analgesics (5%), and amphetamines (4%). Reports of ever having used illicit substances increased slightly from 40% in 2002 to 43% in 2008 [1030]. Further, d’Abbs and MacLean [1034] have highlighted the devastating effects of volatile substance misuse and petrol-sniffing among Indigenous communities in the remote areas of Central Australia. Research has also found that Indigenous Australians are more than twice as likely to be current daily cigarette smokers as non-Indigenous Australians. The percentage of current smokers increased from 33% in 2002 to 45% in 2008, and the proportion of people who had never smoked decreased from 49% to 31% over the same period [1030].

Indigenous people are also over-represented in inpatient mental health services, with twice as many Indigenous than non-Indigenous people hospitalised for a mental illness between 2008–2010 [1030]. Across Australia, the most common mental health conditions requiring hospitalisation were substance- induced mental and behavioural disorders (36%), schizophrenia spectrum and other psychotic disorders (25%), depressive and bipolar disorders (15%), and anxiety disorders (14%). Further, in 2012–13, Indigenous people were almost three times as likely to report high or very high levels of psychological distress [1035]. In 2008–2012, the suicide rate for Indigenous people across all age groups was double the non-Indigenous suicide rate, and five times as high for young Indigenous Australians aged 15–19 years [1035].

It has been suggested that the factors which contribute to elevated rates of psychiatric morbidity in Indigenous communities include the destruction of social infrastructure, rapid urbanisation and poverty, cultural, spiritual and emotional alienation, loss of identity, family dislocation, and increased AOD consumption [1036-1040]. Lee and colleagues [1041] conducted a study of Indigenous women accessing treatment for co-occurring mental health and AOD use disorders. They found that women perceived negative early life events (e.g., domestic violence, physical and sexual abuse) as being associated with the onset of their AOD and mental health conditions. They reported that comorbidity led to severe and wide- ranging negative outcomes, such as general poor health, diminished social networks, unemployment, and financial instability; and they also reported that it 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).

The trauma suffered by the stolen generations as a result of the assimilation policies of the Australian Government has direct relevance to the psychological adjustment of Indigenous Australians by severely disrupting and damaging the quality of early parent–child attachment. A number of studies have found evidence of a direct link between the quality of early relationships and the development of depression in adulthood [1042-1046]. Indigenous people may be at increased risk of poor treatment outcomes due to poor physical health, social disadvantage, comorbidity, and the burden of grief through suicide, homicide, and incarceration [1047, 1048].

Although only limited data exists regarding comorbidity specifically among Indigenous communities, Roxbee and Wallace [1049] report that there are high rates of comorbidity, along with complexities in causality and treatment, which are unique to Australian Indigenous populations. Studies have shown an association between depression, anxiety, suicide, and alcohol dependence in Indigenous communities [1050, 1051]. In addition, frequency of alcohol consumption in Indigenous communities has been found to be correlated with hallucinations, paranoia, self-mutilation, and panic [1038, 1052, 1053]. A survey of Aboriginal admissions to Bloomfield hospital in 1995 showed significant rates of comorbidity [1054]. There is also more recent evidence to suggest that substance use and self-harm behaviour are rising in the Indigenous community [1055, 1056]. Moreover, Indigenous Australians who experience comorbid disorders are likely to have poorer outcomes than those experiencing a mental health or AOD use disorder alone [1057]. However, there is some emerging evidence that interventions for comorbid conditions can lead to beneficial outcomes in Indigenous populations. An RCT conducted by Nagel and colleagues [1058] found that a brief intervention (motivational care planning) for Indigenous people experiencing comorbidity led to reduced symptoms of mental health and AOD use disorders.

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 Indigenous perspectives and needs. Therefore, despite Indigenous Australians having a heterogeneous mix of diverse languages and customs, it is important that AOD workers be aware of general issues and try to familiarise themselves with more specific information regarding the Indigenous population in their community. Reports on this particularly vulnerable group emphasise the need for access to culturally appropriate and comprehensive services to address these problems, and the need for local links with Indigenous services and consultants [99, 1051].

There are a number of general issues to be aware of when working with Indigenous clients [169, 1031, 1060- 1065]:

• The concept of family (including extended family and relatives) and community in Indigenous 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 [1041]. Community and Indigenous support groups may also be useful services.
• Many Indigenous Australians have a holistic concept of health, which is often referred to as social and emotional wellbeing [1059]. This multifaceted concept reflects the Indigenous 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 an individual’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 [1041, 1048].
• There are high rates of trauma, grief, and loss in Indigenous communities as Indigenous people are faced with death and serious illness within their extended family more often than non-Indigenous 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 [1060].
• 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 Indigenous clients with apparent psychotic symptoms, it is important to clarify the cultural appropriateness of such symptoms. For example, it is not uncommon for some Indigenous 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 Indigenous 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 Indigenous 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 Indigenous 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 Indigenous 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: o Referring to a dead 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 Indigenous 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.

Workers should also be aware of the cultural diversity within Indigenous populations, which is often overlooked [1066]. Differences in cultural identity extend to different languages, accessing traditional lands, practising traditional culture, laws and governance, as well as family and kinship structures [1067]. Recognising and responding to the complexities of Indigenous 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 [1059]. The different forms of distress experienced by Indigenous people, as well as the different pathways to recovery, need to be identified, which depend on a diverse range of beliefs and experiences [1068].

Following interviews with Indigenous women experiencing comorbidity, Lee and colleagues [1041] identified a number of improvements that could be made to services to better address the needs of Indigenous people with mental health and AOD use disorders, including:

• Better integration of mental health and AOD services, and greater collaboration between these services and other organisations (e.g., housing, education).
• More promotion of available services (e.g., active presence of mental health/AOD workers at local community events).
• More 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 [1069].
• 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).

AOD workers may find the IRIS (described in Chapter B2) useful in assisting to identify Indigenous clients with AOD and mental health conditions and mental health risks [323].