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20 years after Burdekin: mental health a ‘circuit breaker’ for closing the Indigenous health gap

Twenty years ago the landmark Burdekin Report into the human rights of people with mental health issues identified a crisis in Indigenous communities with high rates of mental health and subtance abuse issues and a lack of culturally appropriate responses.

Among its findings, which were released on 20 October 1993, were that:

  • Mental illness amongst Indigenous Australians ‘cannot be understood in the same terms’ as that amongst non-Indigenous Australians.
  • Previous neglect meant that not enough was known about the prevalence of mental illness amongst Indigenous Australians.
  • The dispossession of Indigenous Australians, the removal of children from their families, and their continuing social and economic disadvantage had created widespread mental health problems, but mental health services rarely dealt with the underlying grief and emotional distress they experienced.
  • In the 1990’s Indigenous people were still being removed from remote communities for treatment in town, which was frequently destructive to their mental health – particularly for elderly people.
  • Much anti-social and self destructive behaviour witnessed in Indigenous Australians was ‘either undiagnosed, misdiagnosed or treated as a police problem’, which led to contact with the criminal justice system, where Indigenous people were labelled as socially deviant – and their mental health problems exacerbated. Many young men spent their formative years (between 15 and 19) in prison and were permanently alienated from their communities as a result.

Marking the anniversary of the Burdekin Report, Dr Tom Calma AO and Professor Pat Dudgeon say there have been some important improvements since, notably around the development of an Indigenous mental health workforce and leadership. However they say little on the ground has changed, and some issues seem to have got worse.

They note, particularly, that rates of suicide, hospitalisation for mental health conditions and psychological distress reported among Indigenous Australians are approximately double to that of other Australians, with multiplying effects on disadvantage.  Mental health conditions, substance abuse and suicide have been estimated to account for as much as 22 per cent of the overall health gap between Indigenous and non-Indigenous Australians.

In this comprehensive article below, they outline the cost of mental health issues to the social fabric of Indigenous communities and point to international research showing that  indigenous communities with ‘cultural continuity’ are seeing significantly lower rates of suicide among young people as those under cultural stress. Therefore, they say, support for culture and social and emotional wellbeing must be at the heart of any overall response to Indigenous mental health.

They propose placing mental health at the centre of the COAG Closing the Gap agenda to develop a dedicated national Indigenous mental health plan that looks beyond the health system to include recognition of, and respect for, human rights and to address disadvantage, social exclusion and racism.

***

Dr Tom Calma AO and Professor Pat Dudgeon write:

Twenty years ago the landmark Burdekin Report on our nation’s mental health was launched. For Indigenous Australians it identified a crisis comprising high rates of mental health conditions among us, the dreadful impacts of these on our communities, and the compounding influence of substance abuse. Another factor adding to the situation was inappropriate treatment according to Western models of mental health that were not culturally relevant. The report also proposed ways forward: for increased resources, for our mental health to be understood in its own cultural context, and for providing Indigenous Australians with the training, power and resources to determine our own mental health strategies and within our own terms of cultural reference.

In the 20 years since, much has changed and little has changed.

In 1993 it made little sense to talk of an Indigenous mental health workforce. Since then the training of significant (although still not enough) numbers of Indigenous psychologists (and a couple of psychiatrists), mental health support workers and the emergence of an Indigenous mental health movement means we are well placed to determine our own mental health strategies. We also have a good foundation in the Aboriginal Community Controlled Health Services and bodies like the National Aboriginal and Torres Strait Islander Healing Foundation to move forward and turn such strategies into action.

Yet, there are some areas that seemed to have become worse in the last 20 years. Or perhaps more accurate data collecting has revealed a starker picture than what was assumed in 1993.

In 2013 the rates of suicide, hospitalisation for mental health conditions and psychological distress reported among Indigenous Australians are approximately double that of other Australians and these continue to exacerbate many other ‘disadvantage gaps’ we suffer, including the higher rates of poor physical health, substance abuse, homelessness and unemployment also reported among us.

In particular, one in four prisoners today are Indigenous – even though we comprise only one in 33 of the total population – and the incidence of mental health conditions and substance abuse problems among them is apparent. A 2009 survey of New South Wales prisoners found that 55 per cent of Indigenous men and 64 per cent of Indigenous women reported an association between drug use and their offence. In the same sample group, 55 per cent of men and 48 per cent of women self-reported mental health conditions. In an even more recent Queensland study, at least one mental health condition was detected in 73 per cent of male and 86 per cent of female Indigenous prisoners; with 12 per cent of males and 32 per cent of females diagnosed with post-traumatic stress disorder.

So 20 years on, while we take great pride in the emergence of an Indigenous mental health leadership, we have to temper that pride with a sad sense of déjà vu as little on the ground has changed. This sense is only increased by the issuance of report after report since 1993 making similar findings and recommendations as Burdekin’s. We highlight among others, the Ways Forward report (1995); the Social and Emotional Wellbeing Framework (2004) and the 2012 National Mental Health Commission’s inaugural Report Card. These consistently identify the following as critical factors:

  • the cultural differences between Indigenous and non-Indigenous constructs of mental health and the positive relationship of culture to Indigenous mental health;
  • the compounding effect of substance abuse and the impact of negative social determinants, including racism, on Indigenous mental health;
  • the need for Indigenous leadership and partnership in any response;
  • the need for dedicated, culturally appropriate planning around our mental health apart from mainstream mental health planning; and
  • the need for an increase in resources and services, and in particular for a dramatic increase in the Indigenous mental health and suicide prevention workforce. Further, for the entire mental health workforce to be culturally competent, or able to work effectively with Indigenous Australians across cultural divides.

Foundations of social and emotional wellbeing

Indigenous Australians often describe their physical and mental health as having a foundation of ‘social and emotional wellbeing’ originating in strong and positive family and community relationships, and relationships to their traditional lands, ancestors and the spiritual dimension of existence. The impact of colonisation on these are well known. Nor do you need to spend a long time in some communities to see the further impact of poor mental health on that community’s ability to support culture and social and emotional wellbeing. Sometimes manifesting as violence and compounded by substance abuse, poor mental health undermines law and lore, positive family and other relationships, indeed the very social fabric.

Social and emotional wellbeing and culture can be understood as protective factors against the stressors and negative social determinants (including sickness, poverty, disability, racism, unemployment and so on) that can cause mental health conditions. Yet the reality is that for most of us the numerous and intense number of stressors and negative social determinants we face undermines and weakens social and emotional wellbeing and culture. At worst, this can result in negative compounding cycles in which culture and social and emotional wellbeing are unable to fulfil their protective role and that leads to further mental health conditions that further undermines culture and social and emotional wellbeing – and so on.

For Stolen Generations Survivors, who report mental health conditions at a higher rate than those not removed, healing – including by strengthening cultural connections and thereby supporting social and emotional wellbeing – is critical but can be particularly challenging.

Support for culture and social and emotional wellbeing must be at the heart of any overall response to our mental health and suicide rates. We are particularly excited by international research that associates Indigenous communities with ‘cultural continuity’ having significantly lower rates of suicide among their young people than communities under cultural stress. It is thought that young people from a strong cultural background have a sense of their past and their traditions and are able to draw pride and identity from them. By extension, they also conceive of themselves as having a future (as bearers of a continuing stream of culture). Cultural continuity can be understood in broad terms as self-determination and cultural maintenance. In the research discussed above, a range of cultural continuity indicators was identified. These included: self-government; land claims; community-controlled services; knowledge of indigenous languages; women in positions of leadership; and facilities dedicated to cultural purposes. The number of indicators present correlated to decreased suicide rates in communities.

Related research and programs in our communities support that there is a high level of need for a range of culturally appropriate and locally responsive healing, empowerment and leadership programs and strategies. Critical to the success of these responses is a high level of community ownership and support. Particularly in relation to suicide prevention, the evidence base suggests that community-developed solutions, based on an acknowledgement of the importance of social and emotional wellbeing, empowerment and cultural renewal, may be key.

Indigenous-led planning

A first order of business then for any body proposing to close the mental health and suicide gap is to strengthen social and emotional wellbeing and culture. This is something that Indigenous Australians must lead: not only is it their human right in relation to decision-making in these areas but, even with the best will in the world, Australian governments and non-Indigenous ‘experts’ and bureaucrats are ill-equipped to work in this profoundly cultural space. Indeed Indigenous-led planning and service-delivery partnerships with Australian governments and their agencies at all levels should be the defining feature of the response proposed here. In particular, we need to capitalise on the roll out of Medicare Locals: to encourage partnerships with them and the Aboriginal Community Controlled Health Services to improve our peoples’ access to mental health and suicide prevention services and specialists.

Partnership means Australian governments listening to Indigenous Australians and their mental health leadership and representative bodies. For too long, the capital in Indigenous knowledge, leadership and lived experience has been marginalised and undervalued in this space; as they have been consistently across all spaces. Indigenous Australians must be respected and must sit as partners at the table with Australian governments at all levels with shared decision-making power.

Mental health as a ‘circuit breaker’

Such a partnership at the national level is critical because there is currently no overarching dedicated strategic response to closing the mental health gap that both pulls together all the causal threads and recognises mental health as a potential ‘circuit breaker’ in so many areas of disadvantage. Instead, strategic responses to Indigenous mental health are scattered and subsumed into the (general population) National Mental Health Strategy and the Indigenous-specific National Aboriginal and Torres Strait Islander Health Strategy with neither providing the required dedicated focus. Further, while the renewed Indigenous Social and Emotional Well Being Framework and the Indigenous drug and alcohol strategy in development are welcome, it is not clear how they will work together towards a common goal, avoid duplication and complement the finalised National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.

Because of this, we advocate for the placing of mental health at the centre of the COAG Closing the Gap Agenda and we support the recommendations of the National Mental Health Commission’s 2012 Report Card for a national target to close the Indigenous mental health gap and dedicated national Indigenous mental health plan to be included there. So placed, these could inform a nationally consistent response that includes an address to determinants beyond the health system that impact our mental health: these include recognition of, and respect for, our human rights, and a national address to racism, as well as the address to disadvantage and social exclusion that already comprises much of the Closing the Gap Agenda.

Conversely, such an approach could also harness the contribution closing the mental health gap could make to closing the many Indigenous disadvantage gaps. This includes in relation to the existing COAG target to close the (at least 10 year) gap in Indigenous life expectancy by 2030. Mental health conditions, substance abuse and suicide have been estimated to account for as much as 22 per cent of the overall health gap measured in Disability Adjusted Life Years, yet this is not reflected in current policy.

Justice re-investment and cultural competence

In a climate of economic restraint the contribution a more equitable and effective use of mainstream mental health resources and funding can make to closing the mental health gap, including through service-delivery partnerships between Aboriginal Community Controlled Health Services and Medicare Locals, must be explored.

Further, investing in our mental health services should also be considered as a justice re-investment measure. ‘Justice reinvestment’ is a name for policies that divert a portion of the funds for imprisonment to local communities where there is a high concentration of offenders. The money that would have been spent on imprisonment is reinvested into services that address the underlying causes of crime in these communities.

Overall, Indigenous Australians have significantly lower access to mental health services, private or public, than other Australians and it thus makes sound policy and economic sense that investing in mental health services for Indigenous Australians should be one avenue to explore through justice reinvestment programs.

A recent cost-benefit analysis by the National Indigenous Drug and Alcohol Committee reported that $111,458 per offender could be saved by diversion to community residential rehabilitation programs when compared to the costs of imprisonment. This sort of modelling supports the justice reinvestment argument that imprisonment simply does not make good economic sense, and – conversely – that investing in mental health services in our communities does.

However, it is important to make the right kinds of investment. This includes in, wherever possible, Aboriginal Community Controlled Health Services that work holistically with their clients and that offer integrated social and emotional wellbeing, substance abuse and suicide prevention services. It is also critical to train more Indigenous Australians to work at all levels of the mental health system to meet our needs, and also to ensure that the non-Indigenous workforce is culturally competent. Today – with GPs playing an increasing role in the mental health system – this includes GPs.

Cultural competence, or effective cross-cultural communication, is often mystified but it is not a hard concept to understand. It includes cultural awareness, or understanding the role of cultural difference and diversity, and the capacity for self-reflection as to how the Western dominant culture impacts on both Indigenous and non-Indigenous Australians. Valuing our peoples and our cultures on our own terms and within our own frames of reference is also vital, as is a commitment to our self-determination and building respectful partnerships with us in our healing journeys.

Time to meet the challenge

Finally, there is an urgent need for a more holistic and coordinated approach to addressing the determinants of our mental health and social and emotional wellbeing. Red-tape reduction and the breaking down of the artificial walls between the many government departments and agencies with responsibility for mental health and social and emotional wellbeing programs is critical; and the same applies to the complementary programs that strengthen culture like native title, caring for country, Indigenous protected areas, cultural and language and inclusion programs. All should be harnessed to improve our mental health and not work at cross-purposes. This is another reason why the dedicated mental health planning we advocate, and that takes all of these areas of government into account, is so important.

Twenty years ago today, the Burdekin Report threw down a challenge to this nation that it is yet to rise to. In the years since many of the issues identified for Indigenous Australians have only got worse. We call on Australian governments to take the Burdekin Report’s recommendations and others since to heart, and to recognise there is an unacceptably large Indigenous mental health and suicide gap, and the impact of mental health conditions on so many areas of disadvantage. We call on all Australian governments and non-Indigenous service providers to enable Indigenous Australians to drive a national response and to partner with them to progress the solutions identified 20 years ago today and that have stood the test of time.

Dr Tom Calma was previosly Aboriginal and Torres Strait Islander Social Justice Commissioner and Race Discrimination Commissioner, and is Adjunct Associate Professor at the National Centre for Indigenous Studies at the Australian National University. Pat Dudgeon, acknowledged as Australia’s first Indigenous psychologist, is Professor with the School of Indigenous Studies at the University of Western Australia and a National Mental Health Commissioner.

An edited version of this article was first published in The Weekend Australian on 19 October.

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