Aboriginal and Torres Strait Islander mental health workers

Position statement Last updated: Aug 2016 Published in Australia Reference: PS #50

Aboriginal and Torres Strait Islander mental health workers bring valuable skills and knowledge to the practice of psychiatry.

Background

This document has been developed by the RANZCP’s Aboriginal and Torres Strait Islander Mental Health Committee in response to a general sense of frustration with often inappropriate utilisation or consultation with, as well as the lack of recognition of the value and skills of, Aboriginal and Torres Strait Islander mental health workers by other professionals and managers in health services. The position statement reflects common themes that have been raised by Aboriginal and Torres Strait Islander mental health workers over a number of meetings, workshops, conferences and discussions.

Aboriginal and Torres Strait Islander mental health workers have expressed the hope that, as leading providers of mental health care in Australia, the RANZCP will play a leadership role in educating mental health professionals about the value of their work. With this in mind, this statement has been developed with the aim of improving the professional standing of Aboriginal and Torres Strait Islander peoples employed to deliver social, emotional, cultural, spiritual or mental health care, or a mixture of all five, to Aboriginal and Torres Strait Islander peoples. This document also aims to develop the capacity of health services to deliver culturally safe and appropriate services to consumers, thereby improving outcomes for the whole community.

Definition

‘Aboriginal and Torres Strait Islander mental health worker’ is a broad term that refers to Aboriginal and Torres Strait Islander peoples working in a wide range of roles in both governmental and community-controlled organisations with varied qualifications, skill sets and criteria. These practitioners may be working in the area of mental health or emotional, social and spiritual well-being, cultural liaison and community engagement, or a combination.

For ease of definition, the term ‘mental illness’ will be used in this document to refer to conditions related to emotional, social and spiritual well-being, or distinct mental health conditions. This is in recognition of the fact that mental health, from an Aboriginal and Torres Strait Islander perspective, encapsulates multidimensional factors, including emotional, social and spiritual well-being, connection to country, culture, ancestry, family and community (Gee et al., 2014).

As such, Aboriginal and Torres Strait Islander mental health workers may work directly with Aboriginal and Torres Strait Islander consumers experiencing a distinct, formally diagnosable mental illness, as well as with those whose illness is understood in more holistic terms.

Evidence

Many Aboriginal and Torres Strait Islander peoples enjoy good mental health and a strong and positive sense of emotional, social and spiritual well-being. However, indicators continue to show that there is a significant portion of the Aboriginal and Torres Strait Islander population who continue to experience very high levels of psychological distress, hospitalisation for mental health disorders, self-harm and suicide. This includes Aboriginal and Torres Strait Islander adults experiencing high or very high psychological distress at almost three times the level of non-Indigenous adults, Aboriginal and Torres Strait Islander peoples being hospitalised for mental and behavioural disorders at twice the rate of non-Indigenous Australians, and hospitalisation rates for self-harm increasing by 50% between 2005 and 2013 whilst the rates for non-Indigenous Australians remained stable (Productivity Commission, 2014).

It has been identified that a complex range of historical and environmental factors have contributed to the discrepancies between Aboriginal and Torres Strait Islander and non-Indigenous mental health indicators, including intergenerational impacts of colonialism and the Stolen Generation, experience of racism, lower access to education, employment and services, higher levels of domestic violence and substance misuse (RANZCP, 2015). Trauma and grief as a result of past dislocation and mistreatment, loss of cultural identity and lack of access to culturally appropriate services have also been found to contribute to higher levels of suicide specifically in Aboriginal and Torres Strait Islander communities (Productivity Commission, 2014).

These indicators reinforce the fact that the complexity of mental illness issues for Aboriginal and Torres Strait Islander peoples necessitates an understanding of a range of cultural, historical, familial and societal issues. Language, stereotyping, stigma and mental health literacy may also pose barriers to Aboriginal and Torres Strait Islander consumers accessing appropriate and effective care. Aboriginal and Torres Strait Islander mental health workers have an important role to play in the negotiation of these barriers.

Given the complexity of the history, conceptualisation and experience of mental health in Aboriginal and Torres Strait Islander communities, Aboriginal and Torres Strait Islander mental health workers have an important role to play in providing direct, holistic care to consumers and communities. Furthermore, where non-Indigenous mental health workers are working with Aboriginal and Torres Strait Islander consumers and communities, an essential part of their role is to engage and consult with Aboriginal and Torres Strait Islander mental health workers.

Because of the holistic nature of Aboriginal and Torres Strait Islander health issues, the role of the Aboriginal and Torres Strait Islander mental health workers may extend outside the normal clinical experience of the patient–therapist relationship. Aboriginal and Torres Strait Islander mental health workers may be required to have a role in local community development and to contact patients and families outside the normal geographical and time parameters expected by non-Indigenous practitioners. This flexibility and the nature of relationships may be critical to the effectiveness of their role.

Recommendations

Recognition of the role of Aboriginal and Torres Strait Islander mental health workers

Aboriginal and Torres Strait Islander mental health workers should be an integral part of any multidisciplinary team caring for Aboriginal and Torres Strait Islander consumers and communities, and should be accorded the same privileges available to any other member of their team.
Non-Indigenous team members have a responsibility to engage with Aboriginal and Torres Strait Islander peoples in a culturally appropriate manner.
Aboriginal and Torres Strait Islander mental health workers have important roles in providing consultation and liaison on cultural safety and security to the team.
Aboriginal and Torres Strait Islander mental health workers have important additional roles in providing peer education on cultural competency, and consultation on specific consumers.
Organisations should be mindful of the diversity of Aboriginal and Torres Strait Islander cultures, and employers should be guided by Aboriginal and Torres Strait Islander mental health workers regarding communities and customs they have insight into, and those they do not. In cases when there is not familiarity with a particular community, Aboriginal and Torres Strait Islander mental health workers should be supported to engage with relevant Elders and community members as required.
Where appropriate, and within the bounds of the relevant state, territory and/or federal legislation, position descriptions should be sensitive to gender issues in Aboriginal and Torres Strait Islander communities, including the preference of consumers to be treated by someone of the same gender.
When developing position descriptions, an awareness of the particular needs of the local Aboriginal and Torres Strait Islander communities should be applied. This may include the need for expertise in child and adolescent mental health, juvenile justice or substance misuse.
Position descriptions for Aboriginal and Torres Strait Islander mental health workers should also recognise the additional expertise, knowledge and skills that applicants bring to the position, for example by way of social and cultural background.
Aboriginal and Torres Strait Islander mental health workers should be involved in service and policy development and models of care.
Aboriginal and Torres Strait Islander peoples should be involved in the development of job descriptions, recruitment and retention strategies for Aboriginal and Torres Strait Islander mental health workers.

The value of work

Aboriginal and Torres Strait Islander mental health workers should receive a salary and employment conditions at least commensurate with non-Indigenous health care providers, and reflective of their value to the organisation, their skills, cultural competency, qualifications and the demanding nature of their roles.
The positions Aboriginal and Torres Strait Islander mental health workers fulfil can be demanding, and may often require commitments outside the time and geographical boundaries followed by non-Indigenous mental health workers. These issues should be taken into account in any statistical and accreditation process affecting the organisation employing the Aboriginal and Torres Strait Islander mental health worker.
There should be a realistic career path with opportunities for professional and managerial advancement for Aboriginal and Torres Strait Islander mental health workers within their employing organisation.
Continuity of health workers, including the employment of trainees who have gained valuable skills and knowledge of their local community can be of great value in Aboriginal and Torres Strait Islander communities. Where possible, these issues should be taken into account in the development of programs for Aboriginal and Torres Strait Islander mental health workers.
Aboriginal and Torres Strait Islander community leaders and Elders who may have no formal educational qualifications often possess a unique knowledge and particular skill in responding to mental health issues within their community. The lack of formal qualifications should not be an absolute barrier to the employment of Aboriginal and Torres Strait Islander mental health workers.

Training

There are a number of training courses offered by tertiary institutions, governmental organisations and community-controlled organisations for Aboriginal and Torres Strait Islander mental health workers. The diversity of courses reflects the diversity of community expectations about the roles of Aboriginal and Torres Strait Islander mental health workers, while emphasising core clinical knowledge. Aboriginal and Torres Strait Islander mental health workers who have engaged in these types of courses should be appropriately remunerated and given appropriate responsibility for their level of training.
Cultural awareness courses are a valuable tool for any service working with Aboriginal and Torres Strait Islander peoples, and may feature in accreditation of such services in the future. The attendance of health workers at such courses should be credited as part of their continuing education. While Aboriginal and Torres Strait Islander mental health workers may wish to contribute to these sessions, they should not be required to take an organisational role when there are educational units or similar available.
Some cultural competency courses may be unnecessary or re-traumatising for Aboriginal and Torres Strait Islander peoples, and mandatory attendance may not always be appropriate in these instances.
There should be appropriate mentoring, debriefing and supervision made available to Aboriginal and Torres Strait Islander mental health workers on an ongoing basis. This should include opportunities for clinical and cultural supervision. Arrangements for this should be established at the time that the Aboriginal and Torres Strait mental health worker is formally appointed.
Supports for Aboriginal and Torres Strait Islander mental health workers should take into account the particular stress and potential for distress involved with working across two cultures.

Resource allocation

Mental health organisations must recruit a sufficient number of Aboriginal and Torres Strait Islander mental health workers so as to prevent over-work, burnout and also to take account of gender issues.
Aboriginal and Torres Strait Islander mental health workers should be supported with appropriate resources to enable them to do their work effectively. Such resources may include office space, culturally appropriate translating services, transport and communication equipment.
Allocation of resources extends to requiring access to culturally secure and appropriate meeting rooms or engagement space to conduct meaningful work.
It should be recognised that Aboriginal and Torres Strait Islander mental health workers, as part of their ongoing cultural supervision, may need regular opportunities to return to country and Elders.
The work conditions for Aboriginal and Torres Strait Islander mental health workers, as with any other worker in the organisation, should be in accordance with occupational health and safety requirements.
Aboriginal and Torres Strait Islander mental health workers should have the opportunity to review the budget allocation for their position.
In some instances it may be appropriate for Aboriginal and Torres Strait Islander Elders and other community members to form a committee of support for Aboriginal and Torres Strait Islander mental health workers. These committee members should be remunerated and supported appropriately.
Research into Aboriginal and Torres Strait Islander mental health is an important avenue for developing more evidence-based, culturally appropriate and efficacious approaches to improving well-being in these communities. Aboriginal and Torres Strait Islander mental health workers should have the opportunity to be involved in research that is acceptable and in accordance with the relevant guidelines for ethical conduct (NHMRC, 2003).

Responsible committee: Aboriginal and Torres Strait Islander Mental Health Committee

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.

References

Gee G, Dudgeon P, Schultz C, Hart A, Kelly K (2014) Aboriginal and Torres Strait Islander Social and Emotional Wellbeing. In: Dudgeon P, Milroy H, Walker R (eds) Working Together: Aboriginal and Torres Strait Islander Mental health and Wellbeing Principles and Practice. Canberra, Australia: Commonwealth Government, pp. 55–68. Available at: aboriginal.telethonkids.org.au/media/699863/Working-Together-Book.pdf (accessed 22 August 2016).

National Health and Medical Research Council (2003) Values and Ethics: Guidelines for ethical conduct in Aboriginal and Torres Strait Islander Health Research. Canberra, Australia: Commonwealth Government.

Productivity Commission (2014) Overcoming Indigenous Disadvantage: Key Indicators 2014 Report. Canberra, Australia: Commonwealth Government.

Royal Australian and New Zealand College of Psychiatrists (2015) Position Statement 42: Stolen Generations. (accessed 22 August 2016).